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   Table of Contents - Current issue
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October-December 2018
Volume 7 | Issue 4
Page Nos. 159-209

Online since Monday, December 31, 2018

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REVIEW ARTICLE  

Systemic review and meta-analysis of diagnostic efficacy of fractional flow reserve using computed tomography angiography for first-time diagnosis of coronary artery disease Highly accessed article p. 159
Narendra Kumar, Ajay Kumar Sinha, Pramod Kumar, Arun Kumar Jha, Karuppiah Arunachalam, Sanjeev Kumar, Ahmad Zakariya, Shaimaa Mostafa
DOI:10.4103/rcm.rcm_28_18  
Coronary artery disease is a leading global cause of mortality. It can be diagnosed by fractional flow reserve (FFR) estimation using computed tomography (CT) angiography. This systematic review aims to review the literature about the diagnostic efficacy of FFR estimation using CT scan (FFR-CT) for the diagnosis of coronary artery disease. The dual databases of Medline and Cochrane Central Register of Controlled Trials were searched for relevant literature from their inception till August 15, 2017. The methodological quality was assessed using the Cochrane risk of bias tool. Pooled estimates of specificity and sensitivity were assessed with the corresponding 95% confidence intervals (CI). After careful screening, five studies involving a total of 296 patients were included in the study. For FFR-CT, on meta-analysis of the pooled risk ratio per patient, random-effects model value was 3.79 (95% CI, 2.93–4.90) and odds ratio per patient was 11.78 (95% CI, 8.08–17.17). The odds ratio by year to see if heterogeneity is due to sample size was 2.50 (95% CI, 1.06–5.91). FFR-CT appears to be a reliable and efficacious noninvasive imaging modality, as it demonstrates high accuracy in the determination of anatomy and lesion-specific ischemia, which justifies the performance of additional randomized controlled trials to evaluate the clinical benefits of FFR-CT-guided coronary revascularization.
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ORIGINAL ARTICLES Top

Thromboembolic disease - Etiological factors and diagnostic approach p. 165
Edis Dzino, Edin Begic
DOI:10.4103/rcm.rcm_26_18  
Background: The aim of the article was to define etiological factors for the occurrence of thromboembolism venous and arterial segments and preview of the sensitivity and specificity of diagnostic procedures in the treatment algorithm. Patients and Methods: The study included 60 patients during the 4-year period. The patients are classified into two groups according to the type of thromboembolism, in the group under the diagnosis of venous thromboembolism and group under the diagnosis of arterial thromboembolism. Results: Statistical analysis showed that arterial thromboembolisms occurred statistically significant later in comparison to venous (t = 4.0969; P = 0.0001). The mortality relationship with all analyzed parameters (age, erythrocytes, hemoglobin, platelets, gender, D-dimer, fibrinogen, immobility, veins surgery, pregnancy, smoking, orthopedic trauma, neoplasms, and pulmonary embolism) showed that statistically significant association was observed only in the case of pulmonary embolism. Conclusion: Biochemical parameters of the blood of patients; red blood cell count, hemoglobin concentration, and platelet counts in the study conducted showed a positive relationship with the occurrence of venous thromboembolism while D-dimer and fibrinogen present in increased values in most patients with venous and arterial thromboembolism. Pulmonary embolism directly affects the outcome of patients with thromboembolic diseases taking into account that in the study conducted in venous thrombosis complicated pulmonary embolism resulted in deaths.
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The value of pre admission Thrombolysis in Myocardial Infarction (TIMI) Risk Index (TRI) in the prediction of no-reflow phenomenon after primary percutaneous coronary intervention in patients presented with ST Segment Elevation Myocardial Infarction (STEMI) p. 169
Metwally H Elemary, Eman S Elkeshk, Fathy M Swailem, Mohammed S. Abd Elhafeez
DOI:10.4103/rcm.rcm_30_18  
Background: Coronary artery disease and acute coronary syndrome (ACS) are the major causes of death, worldwide. Risk assessment for patients with ACS is necessary to minimize morbidity and mortality. The global registry of acute coronary events risk score (GRS), the in thrombolysis myocardial infarction (TIMI) risk score (TRS), and the TIMI risk index (TRI) have been used for patients with ACS to evaluate their risk. We showed at our study the value of pre-admission TRI, TRS, and GRS in occurrence prediction of no-reflow (NRF) Phenomenon after primary PCI for ST-elevation myocardial infarction (STEMI) patients; and its impact on the in-hospital outcome for those patients. Patients and Methods: Our study included 319 patients presented with STEMI and managed by primary PCI. For all patients, we recorded a detailed history, clinical examination as well as Killip class, electrocardiogram, and echocardiography. TRI as well, TRS, and GRS were calculated for all patients. We observed all patients during their PCI at the catheterization room to monitor the result of the intervention. NRF was defined as TIMI flow grade less than III or TIMI flow Grade III with myocardial blush grade less than or equal to II. Then, we followed the patients during their hospitalization period to record any associated complications and mortality. Results: We found NRF patients older than reflow patients, thus regarding age. They were more males. Killip Class III-IV was found to be more common in NRF patients. TRI as well, TRS and GRS showed higher values among the NRF patients. As well, in-hospital major adverse cardiac events (MACEs) and mortality were more common in NRF patients. Conclusion: We found that the high TRI values were related to the occurrence of NRF, in hospital MACE, and mortality.
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Sensitivity, specificity, and accuracy of left ventricular systolic function indices and structure in detecting early systolic dysfunction assessed by speckle-tracking two-dimensional strain: An echocardiographic cross-sectional study p. 176
Ahmadou Musa Jingi, Daniel Czitrom, Ba Hamadou, Leila Mankoubi, Smaali Sondes, Samuel Kingue
DOI:10.4103/rcm.rcm_18_18  
Background: Reduced global longitudinal strain (GLS) is an early marker of subclinical left ventricular (LV) dysfunction, permitting timely interventions to slow disease progression. This technique is not widely available in echocardiographs in routine use. Aim: We sought to know if LV systolic function indices and structural left heart changes could predict a reduced GLS. Methods: We carried out a cross-sectional analytic study in May 2017. We measured GLS (reference test), LV ejection fraction, LV midwall shortening (MWS), LV mass index, LV diastolic diameter, LV volumes, and left atrial volume (predictors). We calculated the sensitivity, specificity, accuracy, predictive values, and likelihood ratios of the predictor variables. We assessed the discriminatory power of the indices with the Youden Index and area under the receiver operator characteristic curve (AUC). Results: A total of 32 participants (14 males) were retained for this study. Their mean (standard deviation) age was 62 (15.3) years. Eccentric LV hypertrophy (LVH) was the most frequent LV geometric pattern – 14 (43.8%) participants. A reduced GLS was the most frequent LV functional anomaly – 20 (62.5%) participants. A low MWS <36.5% had a good predictive power of a reduced GLS – sensitivity: 80%, specificity: 83.2%, accuracy: 81.3%, and AUC: 0.817. The presence of LVH had a fair prediction power of reduced GLS – sensitivity: 70%, specificity: 81.8%, accuracy: 65.6%, and AUC: 0.741. The composite of MWS <36.5% and or LVH had a fair discriminatory power (AUC: 0.783, Youden Index: 0.567), with a good sensitivity – 90%. Conclusion: Low MWS of the LV and the presence of LVH were found to be good predictors of reduced GLS.
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The prevalence of arrhythmias in congenital heart patients and the response rate to antiarrhythmic treatment; A single center study p. 182
Mina Jamlou, Zahra Khajali, Amirfarjam Fazelifar, Mostafa Miri
DOI:10.4103/rcm.rcm_17_18  
Background: Congenital heart disease (CHD) in adults can be associated with several complications, one of the most important of these complications is cardiac arrhythmias. Accordingly, we decided to study the prevalence of arrhythmias in congenital heart patients and the response rate to antiarrhythmic in patients referred to Shahid Rajaee Hospital in the last 10 years. Materials and Methods: In this descriptive-analytical cross-sectional study, 110 patients with CHD referred to Shahid Rajaee Hospital in the last 10 years were selected and were included in the study. The incidence of arrhythmias was determined in them based on the electrocardiogram. In addition, the type of treatment and the response rate to the treatment were studied in patients. Results: In this study, the mean age of patients was 33.73 ± 13.15 years. Among patients, 59 (53.6%) cases were male and 51 (46.4%) were female. Three of the most common symptoms were palpation in 53 (48.2%) cases, dyspnea in 27 (24.5%), and vertigo in 16 (14.5%). The most common type of arrhythmias was atrial flutter in 35.5%, followed by atrial fibrillation in 28.2% and CHB 19.1%, respectively. The most commonly used type of treatment for patients was electrical cardioversion (32.7%), pace (23.6%), and drug cardioversion (22.7%), respectively. The response rate was 94.5% Returning to sinus rhythm, 3.6% continued arrhythmias, and 1.8% turned into other arrhythmias. Based on the duration of postoperative arrhythmias in patients, the highest frequency was observed for 10 years after surgery, which was observed in 49 (44.5%) patients, and thereafter 1 day after surgery in 18 (16.4%) and 1 week after surgery in 12 (10.9%) cases. The association of arrhythmias with treatments for patients regarding palliative status was investigated, which was not statistically significant (P = 0.774) the association of arrhythmias with treatments for patients regarding repaired was investigated, which was statistically significant (P = 0.0001). There is a significant relationship between arrhythmias with QRS duration (P = 0.0001). There is a significant relationship between arrhythmias with right ventricular aneurysm and cyanotic disease (P < 0.05). Conclusion: The current study provides an example of the frequency, diagnosis, and treatment of arrhythmia in patients with congenital heart failure. This study mainly focused on arrhythmias in adults with CHD. However, today, the majority of CHD can be treated with surgical or interventional therapy; however, it is not yet known how arrhythmias occur in patients with CHD.
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Change of “Left atrium ejection force” after transcatheter “Atrial septal defect” closure using “AMPLATZER,” in pediatric patients p. 187
Hassan Esmaeili, Kourosh Vahidshahi, Maryam Moradian, Hojjat Mortezaeian
DOI:10.4103/rcm.rcm_3_18  
Background and Purpose: There has not been any study regarding atrial systolic function in transcatheter atrial septal defect (ASD) closure. The aim of this study was to survey left atrium ejection force in this procedure in the pediatric age group. Subjects and Methods: This was an observational (before and after) study. Pediatric patients who underwent transcatheter ASD closure using “AMPLATZER” at “Rajaei Cardiovascular Medical and Research Center,” from March to December 2013, were enrolled consecutively. Physical examination and transthoracic echocardiography were performed for the patients before and 12–24 h after the procedure, and left atrium ejection force was calculated. Results: Totally, 63 patients (age: 6.11 ± 3.43 [1–14] years and weight: 21.53 ± 10.79 [9.7–48] kg) were studied. ASD size was 11.43 ± 3.30 (5–22) mm. Left atrium ejection force, before and after the procedure, was 7.19 ± 6.06 (0.33–32.54) kilodyne and 6.30 ± 4.03 (0.5–18.16) kilodyne, respectively (P = 0.28). There was no significant difference between pre- and postprocedure left atrium ejection force in different age group, both genders, types of the device, and ASD size. Postprocedure left atrium ejection force was significantly lower in the patients with large devices (diameter of left atrial disk to body surface area ratio index >40 mm/m2) than smaller device. Conclusion: This study showed that left atrium ejection force after transcatheter ASD closure does not change significantly at early stage, so atrial systolic function is maintained in the presence of the device. In the patients with large device, left atrium ejection force may decrease.
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Three-window ultrasonography confirmation of endotracheal tube placement p. 192
Shadi Lahham, Sean P Wilson, Elizabeth Turner, Mohammad Subeh, Mark A Rosen, Arthur Youssefian, Craig L Anderson, Melika Hosseini, Sasha Rosen, Abdulatif Gari, John C Fox
DOI:10.4103/rcm.rcm_24_18  
Background: Establishing a definitive airway is often an initial step in the management of critically ill patients in the emergency department (ED). Currently, there is no universally accepted gold standard for airway confirmation. Recent literature has shown that point-of-care ultrasound (POCUS) may be helpful in confirming the correct endotracheal tube (ETT) placement. Objective: The objective of this study is to evaluate the accuracy of a comprehensive three-window POCUS assessment to confirm correct ETT placement. Methods: This was a prospective, single-center, observational study using a convenience sample of patients in the ED and Medical Intensive Care Unit. After presumed successful ETT intubation, three sonographic windows were obtained, which included the trachea, bilateral lung sliding, and diaphragm movement. Results: We enrolled a total of 140 patients. There were no esophageal intubations. The three-window POCUS method correctly identified 132 of 137 ETTs placed in the trachea with 96.4% sensitivity (95% confidence interval [CI] 91.7%–98.8%) and 33.3% specificity (95% CI 0.8%–90.6%). Only one of the three mainstem intubations was identified using POCUS. Ultrasound assessment was completed on average 25 min quicker than the usual confirmatory plain film radiography (95% CI 6.2–43.9 min, P = 0.005). Conclusions: The three-window POCUS assessment is a rapid and potentially reliable method to identify ETT intubation, but may not be reliable at confirming mainstem intubation.
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Effect of preinfarction angina on primary percutaneous coronary intervention outcomes p. 197
Hamid Reza Sanati, Samaneh Ahmadi, Melody Farrashi, Parham Sadeghipour, Ata Firouzi, Ali Zahedmehr, Farshad Shakerian, Reza Kiani, Omid Shafe, Seyed Jamal Moosavi, Hooman Bakhshande, Alireza Hoghooghi, Farhad Jalili
DOI:10.4103/rcm.rcm_20_18  
Background: Preinfarction angina has been recognized as a surrogate for preconditioning episodes. This study was designed to evaluate the cardiovascular effects of preinfarction anginal episodes among acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI). Materials and Methods: Of 520 patients who had undergone primary PCI, 393 patients were finally included in a prospective cohort study. Standard primary PCI procedure according to the latest guidelines was performed. The patients were divided into three groups based on previous symptoms as follows: asymptomatic (Group A), chronic stable angina (Group B) and unstable angina (Group C). Results: A total of 393 patients were evaluated. 185 (47.1%) patients were described as asymptomatic, 48 (12.2%) had stable angina and 160 (40.7%) were categorized as unstable angina. There was no significant difference among the study groups regarding pre- and post-PCI thrombolysis in myocardial infarction flow grade (P = 0.81). Median of peak post-PCI creatine-kinase-muscle/brain level of Group A (asymptomatic) was 250.5 (115.5–389), and it was significantly higher than Group C (176 [60.00–313.50]) (P = 0.03). Q wave formation was observed in 142 (88.75%), 31 (64.5%), and 96 (52.0%) patients of Group A, B, and C patients, respectively, which was significantly higher in asymptomatic patients (P = 0.002). There was no significant difference among the three groups regarding in-hospital and 6-month mortality (P = 0.36, 0.06, respectively). The composite endpoint of 6-month mortality, acute coronary events, cerebrovascular accidents, and target vessel revascularization was not significantly different between the three groups (P = 0.11). Conclusion: Preinfarction angina among AMI patients undergoing primary PCI seems to have a limited beneficial effect on infarct size, and this benefit was not translated to any clinical benefit.
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CASE REPORTS Top

Importance of imaging for transcatheter aortic valve replacement in dextrocardia with situs inversus totalis p. 203
Dambruoso Pierpaolo, Raimondo Pasquale, Malvindi Pietro Giorgio, Contegiacomo Gaetano
DOI:10.4103/rcm.rcm_25_18  
We describe imaging utility for trans-femoral aortic valve replacement (TAVR) with 29-mm Core-Valve Evolut R self-expanding valve prosthesis in a singular case of an old man with symptomatic severe aortic stenosis (SAS), dextrocardia, and situs inversus totalis. Cardiac computed tomography plays a pivotal role from pre-procedural planning to TAVR by our heart-team. It gives crucial information to choice the appropriate valve sizing, to avoid paravalvular leak, coronaries obstructions, or serious aortic injuries. To the best of our knowledge, this is the first case of TAVR successfully performed in Italy in a patient with symptomatic SAS, dextrocardia and situs inversus totalis.
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Unusual presentation of Takayasu's arteritis with cardiac involvement and renal artery stenosis p. 207
Zahra Khajali, Farzaneh Futuhi, Parham Sadeghipour, Maedeh Arabian, Maryam Aliramezany
DOI:10.4103/rcm.rcm_21_18  
Takayasu's arteritis (TA) is a chronic large-vessel arteritis in which the aorta, its major branches, and the pulmonary arteries are affected. The clinical signs of TA are insidiously varied, depending on the arterial sites involved. In this paper, we report an unusual presentation of TA with signs and symptoms of heart failure and the involvement of the renal artery in a 34-year-old male who was managed with medical treatments and an interventional procedure. Given the unusual presentation of TA, we recommend a high clinical index of suspicion of renal artery involvement and sufficient heed to its significance especially in view of the fact that its early diagnosis and timely appropriate treatment can confer a much better prognosis.
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