Walid Hassan

Improved anticoagulation with a weight-adjusted heparin nomogram in patients with acute coronary syndromes: A randomized trial

The optimal heparin dosing schedule to achieve rapid and therapeutic anticoagulation has not been established. The objective of this study is to determine whether an intravenous heparin dosing nomogram based on body weight achieves adequate anticoagulation more rapidly than a standard-care nomogram. Sixty-four patients requiring intravenous heparin treatment for acute coronary syndromes, but who did not receive thrombolytic therapy, were randomized to a standard-care nomogram in which heparin was given as a 5000 unit IV bolus followed by 1000 U/hr, or a weight adjusted nomogram in which heparin was given as an 80 U/ kg IV bolus and 18 U/kg/hr. Activated partial thromboplastin time (APTT) values were checked at 6,12,18, 24, and 48 hours and adjusted either by 100–200 U/hr (standard-care nomogram) or by 2–4 U/kg/hr (weight-based nomogram). Activated partial thromboplastin times were measured using a widely generalizable laboratory method. The primary goal was to achieve and maintain the APTT between 60 and 90 seconds. The median APTT values were higher in the weight adjusted group compared with the standard-care group at 6, 12, 18, 24, and 48 hours: 150 versus 83 (p=0.001), 100 versus 79 (p=0.09), 66 versus 61 (p=0.005), 63 versus 56 (p = 0.09), and 64 versus 56 (p=0.11). At 18 hours only 11% of patients in the weight-adjusted group had an APTT <61 compared with 26% in the standard-care nomogram (p=0.007). No major bleeding complications were noted in either group. A weight-adjusted heparin nomogram offers improved anticoagulation in the first 24 hours after heparin initiation compared with a standard-care nomogram in patients with acute coronary artery syndromes.

Long-term effects of balloon angioplasty on left ventricular hypertrophy in adolescent and adult patients with native coarctation of the aorta. Up to 18 years follow-up results.

Little is known regarding the long‐term follow‐up results of balloon angioplasty (BA) for patients with native aortic coarctation (AC) on left ventricular hypertrophy (LVH) regression.

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty.

Background: The effect of mitral valve morphology (MVM) on the long‐term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long‐term outcome of MBV. Methods : Five hundred and eighteen consecutive patients (mean age, 31 ± 11 years) who underwent successful MBV were followed up for 0.5–16.5 (mean, 6 ± 4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n = 340; MES ≤ 8) and group B (n = 178; MES > 8). Results: We report the immediate and long‐term clinical and echocardiographic results of the above‐mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0 ± 0.3 vs. 1.82 ± 0.3 cm2, respectively; P < 0.0001) and also at the last follow‐up (1.8 ± 0.33 vs. 1.5 ± 0.33 cm2, respectively; P < 0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P < 0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92 ± 2%, 85 ± 3%, 65 ± 6% for group A vs. 72 ± 4%, 44 ± 5%, 9 ± 6% for group B (P < 0.001). Event‐free survival rates at 5, 10, 15 years for group A were 93 ± 1%, 88 ± 2%, 66 ± 6% vs. 82 ± 3%, 59± 6%, 8 ± 7% for group B (P < 0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area ≤ 1.8 cm2, as predictors of restenosis (P < 0.0001, P = 0.014, P = 0.0015, respectively); MES and age as predictors of event‐free survival (P < 0.0001, P < 0.0001, respectively). Conclusion: MBV has excellent long‐term results in patients with favorable MVM. Favourable MVM is a strong predictor of good long‐term outcome.

Dysphagia Lusoria Caused by Aberrant Right Subclavian Artery, Kommerell’s Diverticulum, Legamentum Ring, Right Descending Aorta, and Absent Left Pulmonary Artery: A Report of a Unique Vascular Congenital Disease Undetected until Adulthood and a Review of the Literature

An active otherwise healthy and middle-aged woman presented with left supraclavicular pulsation, right upper extremity claudication, and mild dysphagia. Evaluation revealed an aberrant right subclavian artery, Kommerell’s diverticulum with aneurysmal degeneration, legamentum arteriosum completing vascular ring, and absent left pulmonary artery with multiple collateral supply to the left lung. She underwent successful surgical repair via right thoracotomy, including division of the vascular ring, resection of the diverticulum and aneurysm, and finally reimplantation of the right subclavian artery to the aortic arch. Her symptoms resolved completely, and she was able to resume normal activities.

The Prevalence, Clinical Characteristics, and Prognosis of Diastolic Heart Failure: A Clinical Study in Elderly Saudi Patients With Up to 5 Years Follow-Up

Data from 519 patients older than 65 years with congestive heart failure (CHF) were analyzed after 5 years of clinical follow-up. Two groups were included in the analysis: 321 patients with ejection fractions > or =50% (group with diastolic heart failure) and 198 patients with reduced ejection fraction <50% (group with systolic heart failure). Hypertension (81%) was the strongest predictor of congestive heart failure, followed by diabetes (46%) and coronary disease (33%). Diastolic heart failure was more predominant in elderly female (P=.007), hypertensive (P=.0001), and hypertrophic (P=.001) patients. Length of hospital stay, readmission rate, all-cause morbidity, and cumulative mortality were not statistically significant between both groups (P=.09).

Immediate and long-term results of percutaneous mitral balloon valvotomy in asymptomatic or minimally symptomatic patients with severe mitral stenosis

The purpose of this study was to evaluate the safety and value of percutaneous mitral balloon valvotomy (PMBV) in asymptomatic or minimally symptomatic patients with severe mitral stenosis (MS). There are very limited data supporting the concept of PMBV in asymptomatic or minimally symptomatic patients with severe MS. We analyzed the results of 539 consecutive patients with severe MS who underwent PMBV at our hospital. Patients were divided according to their symptoms at the time of PMBV into group A (55 patients), who had few or no symptom (NYHA class 1 or 2), and group B (484 patients), who had severe symptom (NYHA class 3 or 4). Patients had clinical and echocardiographic follow‐up for 0.5–15 years. There was no significant difference in baseline characteristics between the two groups. The immediate mitral valve area (MVA) was equal in both groups. The follow‐up MVA was larger in group A (1.9 ± 0.38 vs. 1.7 ± 0.4 cm2; P = 0.002), and restenosis occurred in 11% in group A vs. 23% in group B (P = 0.023). Actuarial freedoms from restenosis at 5, 10, and 13 years were significantly higher for group A than for group B (97% ± 2%, 77% ± 9%, 77% ± 9% vs. 85% ± 1%, 62% ± 3%, 39% ± 5%; P = 0.0018). Atrial fibrillation at follow‐up was encountered in 11% in group A vs. 20% in group B (P = 0.042). There was a significant reduction of the left atrial size in both groups. Event‐free survivals at 5, 10, and 13 years were higher for group A than for group B (97% ± 2%, 80% ± 9%, 80% ± 9% vs. 86% ± 1%, 65% ± 3%, 42% ± 3%; P = 0.0018). This study demonstrated excellent immediate results of PMBV in asymptomatic or minimally symptomatic patients with severe MS and long‐term results are better compared to the reported natural history of such patients. We recommend mitral balloon valvotomy (MBV) for patients with severe MS with few or no symptoms, provided the valve morphology is suitable for MBV.© 2005 Wiley‐Liss, Inc.

Successful Lysis of Intra-Cardiac Thrombi with Streptokinase in Patients with Renal Failure; Two Case Reports and Review of the Literature

In situ formation of thrombi within the cardiac cavities carries a substantial risk of morbidity and mortality due to the inherent danger of embolization to vital organs. This typically occurs in patients with underlying cardiac disorders associated with low flow state favoring regional stagnation of blood and subsequent clotting. Occasionally, extra-cardiac conditions such as renal failure predispose to the development of intra-cardiac thrombi in the presence or absence of identifiable cardiac abnormalities. Once identified, the appropriate treatment of such thrombi remains highly controversial. Here, we report on the successful and safe use of streptokinase in two patients with end stage renal disease with high risk left ventricular, right ventricular and right atrial thrombi.

Right Coronary Artery Anomalous Origin from Left Anterior Descending Artery Detected by Computed Tomography Coronary Angiogram: A Case Report and Review of the Literature

Coronary anomalies are generally rare and recognized in approximately 1.3% of coronary angiograms. The right coronary artery originating from the left coronary system is an extremely rare variation of the single coronary artery anomaly in which the prognosis is usually benign provided that the anomalous vessel does not pass between the aorta and the pulmonary artery. Right coronary artery anomaly can be associated with other congenital cardiovascular anomalies such as bicuspid aortic valve, transposition of the great vessels and tetralogy of Fallot. The clinical significance of coronary anomalies is usually determined by underlying anatomic features of the anomalous coronary origin and/or coronary atherosclerosis. Initial presentations include: chest pain, myocardial infarction, arrhythmias, sudden death, and quite rarely exertion syncope. Although coronary angiography is an important diagnostic method, new non-invasive methods such as coronary computed tomography angiography and cardiac magnetic resonance imaging have important roles to play in characterizing this coronary anomaly. It should be noted that the management strategy of these patients may vary based on clinical presentation and anatomical details. We report a Case of exertion dizziness, diagnosed to have anomalous origin of right coronary artery from left anterior descending artery diagnosed by computed tomography coronary angiography. Medical treatment was effective in relieving the patients symptoms and ischemia.

Improvement of angiodysplasia-derived anemia after transcatheter aortic valve implantation: A case report and literature review

Case summary: Aortic stenosis has been associated with anemia due to bleeding episodes from gastrointestinal angiodysplasia. It had been reported that surgical aortic valve replacement corrects the bleeding from angiodysplasia and the associated anemia. In this report, we present a case of a 79 years old female patient with angiodysplasia-derived anemia improved after transcatheter aortic valve implantation. Correspondence to: Walid Hassan, MD, FACC, FAHA, FCCP, FACP, FSCAI. Professor of Medicine Director, Cardiac Center of Excellence, International Medical Center, P.O. Box 2172, Jeddah 21451, Saudi Arabia, Tel: + 966-12 650 9000; Fax: + 966-12 650 9787; E-mail: hassan_walid@hotmail.com

Long-term clinical outcomes of drug-eluting stents in diabetic patients with small vessels compared to larger vessel-7 years clinical follow-up.

OBJECTIVES The aim of this study was to analyze the effectiveness of drug-eluting stents (DES) in small vessels in patients with non-insulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM). BACKGROUND Several randomized trials have shown DES to significantly reduce the angiographic and clinical events in diabetic patients. However, there is insufficient data on similar outcomes in diabetics with small vessels. METHODS We studied 258 consecutive diabetic patients (173 NIDDM and 85 IDDM) who underwent coronary stenting with DES, divided into 2 cohorts: group A (vessels<2.7mm): 163 patients, and group B (vessels≥2.7mm): 95 patients. We analyzed the major adverse cardiac events (MACE) [death, nonfatal myocardial infarction MI, and target lesion revascularization (TVR)] over a mean follow-up of 78.4±14.8months. RESULTS Group A patients had: smaller reference diameter (2.4±0.31 versus 3.14±0.2mm, p=0.0001), longer lesions (19.3±9.5 versus 16.7±7.1mm, p=0.023), more complex lesions: (B2/C) (80.7 versus 52.6%, p<0.033), bifurcation lesions (25.8 versus 11.6%, p=0.007), diffuse disease (42.9 versus 26.3%, p=0.008), multivessel (32.5 versus 18.9%, p=0.019), eccentric lesions (57.1 versus 43.2%, p=0.031), more stents implanted (1.99±1.6 versus 1.7±1.3, p<0.0001), more overlapping stents (29.4 versus 13.7%, p=0.004) and more stents length (25.7±4.9 versus 20.2±2.6, p<0.003). During the follow-up, both groups had overall similar MACE (10.4 versus 11.7%, p=0.9) with insignificant higher restenosis (9.2 versus 8.4%, p=0.832) and TVR (7.4 versus 6.4%, p=0.75) in group A. There was no difference in death (p=0.111) or MI (p=0.858). Both groups had similar stent thrombosis rate (1.2 versus 1.1%, p=0.899), angina events (10.4 versus 16.8%, p=0.137), abnormal stress thallium (14.1 versus 14.7%, p=0.890), and hospital days (2.91 versus 3.57, p=0.886). CONCLUSION Despite complex angiographic characteristics, the use of DES in diabetic patients with small vessels showed favorable clinical outcomes and similar low TVR compared to those with large vessels.