Reza Kiani

Percutaneous Mitral Valvuloplasty Using Echocardiographic Intercommissural Diameter as Reference for Balloon Sizing: A Randomized Controlled Trial

Percutaneous balloon mitral valvuloplasty is the preferred therapeutic strategy in patients with mitral stenosis, but it has shortcomings in a subset of patients.

Coronary Slow Flow Phenomenon Clinical Findings and Predictors.

Background: In some patients with chest pain, selective coronary angiography reveals slow contrast agent passage through the epicardial coronary arteries in the absence of stenosis. This phenomenon has been designated the slow coronary flow (SCF) phenomenon. Objectives: In this study, we aimed to describe the demographic and clinical findings and presence of common atherosclerosis risk factors in patients with the SCF phenomenon. Patients and Methods: Between October 2014 and March 2015, demographic data, clinical histories, atherosclerosis risk factors, and laboratory and angiographic findings were recorded for all consecutive patients scheduled for coronary angiography and diagnosed with the SCF phenomenon, as well as a control group (patients with normal epicardial coronary arteries; NECA). SCF was diagnosed based on the thrombolysis in myocardial infarction frame count (TFC). A TFC > 27 indicated a diagnosis of SCF phenomenon. Results: Among the 3600 patients scheduled for selective coronary angiography, 75 (2%) met the SCF criteria. SCF and NECA patients did not exhibit statistically significant differences in traditional risk factors except for hypertension, which was more prevalent in SCF than NECA patients (52% versus 31%, P = 0.008). A multivariable analysis indicated a low body mass index, presence of hypertension, low high- density lipoprotein cholesterol (HDL-c) level, and high hemoglobin level as independent predictors of the SCF phenomenon; of these, hypertension was the strongest predictor (odds ratio = 6.3, 95% confidence interval: 2.2 - 17.9, P = 0.001). Conclusions: The SCF phenomenon is relatively frequent, particularly among patients with acute coronary syndrome who are scheduled for coronary angiography. Hypertension, a low HDL-c level, and high hemoglobin level can be considered independent predictors of this phenomenon.

Mitral valve resistance determines hemodynamic consequences of severe rheumatic mitral stenosis and immediate outcomes of percutaneous valvuloplasty

The mitral valve area (MVA) poorly reflects the hemodynamic status of (MS). In this study, we compared the MVA with mitral valve resistance (MVR) with regard to the determination of hemodynamic consequences of MS and the immediate outcomes of percutaneous balloon mitral valvuloplasty (PBMV).

Comparison of Outcomes of Diseased Coronary Arteries Ectasia, Stenosis and Combined

Background: Coronary artery ectasia (CAE) is a localized or diffuse abnormal dilatation of coronary arteries. Controversy still remains about its cardiovascular events rate, prognosis, and etiology. Adverse effects of CAE coinciding with coronary artery stenosis (CAS) (and in isolated form) are unclear. Objectives: We aimed to investigate the cardiovascular event rate of CAE in comparison to ‘CAS only’, and comparing their etiology. Patients and Methods: This cross-sectional study was conducted on 200 patients between May 2011 and June 2012. Of them, 40 had CAE (case group) and 160 had only CAS (control group). Patients with CAE were divided into 2 subgroups according to the absence (E1) or presence (E2) of CAS. They were followed up for at least 6 month for cardiovascular events, including death, unstable angina and myocardial infarction (MI). Finally, we compared findings in CAE, CAS, and E and E2 subgroups and evaluated the relationship between severity of ectasia (1-1.5 times, 1.5-2 times, and > 2 times) and CAS. Results: Hypertension (HTN), dyslipidemia (DLP), and male sex were matched in both groups without significant difference. Cigarette smoking (C/S) was significantly higher and diabetes mellitus (DM) was significantly lower in CAE compared to CAS patients. A subgroup of CAE patients with CAS (E2 subgroup) had significantly higher mortality rate than isolated CAS (P = 0.043). MI was seen in several isolated CAE patients (E1) subgroup. Severity of ectasia showed no significant relationship with CAS. Conclusions: Presence of CAE in patients with CAS increases its cardiovascular event rate. Isolated CAE is not a benign finding and MI can occur. Risk factors of CAE are similar to CAS, but C/S is more associated with CAE than CAS. DM is seen in CAE patients less than CAS.

Comparison of the clinical and morphologic characteristics of culprit lesions in unstable angina and non-ST-elevation myocardial infarction

Objective The aim of the study was to assess the differences in clinical and morphologic characteristics of culprit lesions among patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). Methods The authors included 174 consecutive patients who have been admitted due to UA or NSTEMI. All patients underwent coronary angiography during hospitalisation and angiographic characteristics were determined. Results The mean age of study patients was 57±9 years, and the majority were men. The frequency of single, two and three vessel disease was 35.6%, 28.7% and 28.1%, respectively. There was no significant difference between UA and NSTEMI patients in terms of the extent of coronary artery involvement and culprit lesion morphologic features (p value: 0.99 and 0.67, respectively). The only significant difference was the incidence of definite and possible thrombus in culprit lesion (40.7% vs 16.5%, p value<0.001). The authors also did not find any association between Braunwald clinical/severity classification and lesion morphology in the studied population. In multivariate analysis there was a significant association between Braunwald class II–III and increased risk of NSTEMI (OR (95% CI): 13.43 (1.12 to 160.63), p=0.04, OR (95% CI): 14.08 (1.21 to 163.11), p=0.03, for Braunwald severity class II and III, respectively). Conclusion Clinical characteristics of patients with acute coronary syndrome including enzyme rising cannot predict the extent of coronary artery involvement and the morphology of culprit lesions. The only exception was the higher incidence of intracoronary thrombus in patients with NSTEMI as compared with UA.

Comparison between rosuvastatin and atorvastatin for the prevention of contrast-induced nephropathy in patients with STEMI undergoing primary percutaneous coronary intervention

Introduction: There is some controversy over the efficacy of statins for the prevention of contrastinduced nephropathy (CIN). There have also been reports on varying efficacies of different statins. Hence, in this study the efficacy of atorvastatin and rosuvastatin for the prevention of CIN was assessed. Methods: This single-blind randomized clinical trial was performed on 495 random patients with myocardial infarction with ST-segment elevation undergoing primary percutaneous coronary intervention (PCI) in a training referral hospital in 2015. Patients were randomly assigned to receive either atorvastatin 80 mg at admission and daily or rosuvastatin 40 mg at admission and daily. CIN was defined based on serum creatinine elevation after 48 hours from the PCI. Results: The incidence of CIN was observed in 63 patients (21.4%) After 48 hours from primary PCI. Of those, 17% (n = 50) were grade 1 CIN, while 4.4% (n = 13) were grade 2 CIN. There was no significant difference between rosuvastatin group compared with atorvastatin group, regarding the CIN grading (P = 0.14). Conclusion: Our results indicate that atorvastatin and rosuvastatin have similar efficacy for the prevention of CIN.

Hepatic Radioembolisation of Yttrium-90 Microspheres in Animal Model

Background and Aim: Liver directed therapy utilizing yttrium-90 microspheres represents a recently introduced in situ multidisciplinary cancer therapy that has caught the attention of many physicians faced with the challenges of treating these complex patients. Radioactive particle in capillary liver system were assessed through the in vivo test and the leakage to lung or other organ was defined. The concentration of Y-90 in liver tumor without leakage to the other organ was seen which has the important role in radioactive drug successes by radioimbolization method. Method: Four different phases of Y 90 injection were performed in rabbits; 1. Preparation of Y-90 glasses microspheres, 2. Preservation, preparation and tumorization of the animal lab before and after drug injection, 3. Animal Angiography and injection of radioactive drug in animal liver, 4. Radionucleotide imaging of the animal; an assessment of stabilization of the radioactive particle in liver tumor. Early and late anterior and posterior injection of Y90 microspheres on rabbet showed. Yttrium 90 microspheres concentrated in liver, background, left and right lung were calculated. The mean ± SD was defined for the particle localization. Result: The most Y90 microspheres were localized in late posterior view in rabbet and the less in background; 67.79 ± 19.9 and 13.65 ± 7.97 respectively. Considering the late posterior view the highest total count of particles were mostly seen in the liver and then in the background, 68804 and 12026 respectively. Early posterior injection of Y90 demonstrated the most particles were concentrated in liver 57.82 ± 17.66 and the smallest in the background 19.61 ± 6.63. Regarding early anterior injection, the most average number of the particles was reported 44.35 ± 13.10 in liver and the fewer particles were in background 17.93 ± 5.44. Concerning the late anterior view, the great total numbers of particles were concentrated in liver 1020 and the less in left and right lung with the number of 342. The average particles counts were calculated 79.33 ± 21.55 in the liver and 36.17 ± 8.7 in background. Conclusion: Significantly higher doses of radiation can be delivered to a liver mass by intra-hepatic arterial administration of 90Y-microspheres and the most concentration of the particles were seen in the liver in comparison to the other organ. This treatment appears to be beneficial in non-respectable tumors with acceptable toxicity.

Selenium for the Prevention of Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography and Percutaneous Interventions: A Double-Blinded Randomized Controlled Trial

Background: Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury and is associated with significant morbidity and mortality even if transient or successfully treated. The preventive measures currently available have failed to show significant efficacy. Selenium, which is involved in anti-oxidative reactions, might have protective effects against CIN. Methods: 237 patients undergoing coronary angiography or intervention were randomly assigned to receive placebo (n=120) or selenium (200 mcg daily on the pre-procedural day, procedural day, and the first post-procedural day) (n=117). Serum creatinine was measured before and two days after the procedure. The primary endpoint was the occurrence of CIN within forty-eight hours. Results: Baseline characteristics were not different between the groups. CIN occurred in 13 (11.1%) patients in the selenium group and in 23 (19.2%) in the placebo group (odds ratio (or) 95% confidence interval (CI): 1.72 (0.92-3.24), p value=0.084). Selenium intake was significantly associated with lower rates of CIN in the males (or (95% CI): 2.33 (1.10-5.48), p value=0.04), hypertensive patients (or (95% CI): 2.69 (1.12-7.53), p value=0.04), those with a left ventricular ejection fraction <50% (or (95% CI): 5.38 (1.26-22.9), p value=0.008), and those who underwent percutaneous coronary interventions (or (95% CI): 1.98 (1.01-3.99), p value=0.04). Conclusion: Selenium, as an antioxidant, might decrease the occurrence of CIN, especially in high-risk patients undergoing coronary angiography or percutaneous coronary intervention. Nevertheless, routine recommendation of selenium to these patients needs further investigations.

Traumatic Pseudoaneurysm of Left Anterior Descending Artery Caused by Thoracic Stab Wound Treated with Coil

Trauma is one of the most common causes of death worldwide. Penetrating cardiac injury (PCI) is highly lethal and represents an increasingly important form of traumatic injury. We describe a 25 year-old man suffered stab wound and PCI, as a result of which he underwent surgical thoracotomy for tamponade. He was discharged in good clinical condition and no cardiac perforation was detected. Two weeks later, he presented to our center with prolonged chest pain. Electrocardiography (ECG) and cardiac biomarkers confirmed myocardial damage. Echocardiography showed hypokinesia and thinning (0.6 mm) of the inferoapical wall segment and mildly reduced left ventricular systolic function. Angiography revealed patent left main coronary artery, LAD, left circumflex, and right coronary artery, along with an abnormal aneurysmal structure at the distal part of the LAD. Coil embolization of the distal LAD pseudoaneurysm was performed which was placed to occlude the proximal entry site of the pseudoaneurysm. Angiography confirmed the disappearance of the pseudoaneurysm. The patient was discharged after 48 hours. Follow-up angiography after two months showed no residual leakage across the vessel. Coil embolization of a distal coronary pseudoaneurysm can be performed as an alternative procedure instead of surgical ligation of the small vessels, with good results. It should be emphasized that one should occlude both proximal and distal entry sites to avoid blood leakage.

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.