Background: The current trend of heart transplantation in recent years has taken a quantum leap forward. We decided to look back at our experience in this center. Objectives: Here, we focus on the diagnostic pitfalls and challenges in these biopsies. Patients and Methods: Forty two patients based on the standard protocol of heart transplantation group, yielded 63 biopsy samples over a period of 33 months (April 2010 - December 2012). The mean age was 30.4 years (ranging from 16 to 58 years) with 51 males (81%) and 12 females (19%). All the patients were examined periodically and biopsy samples were taken from the right ventricular wall. Results: Rarely fewer than three pieces of myocardial samples were procured. Scar, adipose tissues and blood clots may be seen instead. Quilty effect (nodular endocardial lesions composed of inflammatory cell infiltrates) was seen in 8 cases (12.7%). Other findings not directly related to rejection including early ischemic injury, Quilty effect and post-transplant lymphoproliferative disorders (PTLD) were not encountered. Conclusions: Specimen inadequacy was not a major problem in our center. It poses a great limitation, because suboptimal specimens sometimes mislead the pathologist. Other findings especially Quilty effect were within the range defined for this finding.

Coarctation complicated with mycotic pseudo-aneurysm is very rare. We are reporting a case of a 26-year-old man suffered from this pathology. As the incidence of mycotic pseudo-aneurysm is very rare in patients with aortic coarctation, the choice of this pathology for a patient presenting with unexplained fever is the only way to reduce the mortality risk.

Background: Current treatment for extensive thoracoabdominal aortic aneurysms (TAAAs) involves high-risk surgical and endovascular repairs, with a hospital mortality exceeding 20%, and a postoperative paraplegia rate beyond 10.5%. Objectives: The aim of this study was to present an estimation of the economic impacts of surgical and endovascular treatments of types II and III TAAAs in the US as well as the economic consequences of the elimination of spinal cord injury and mortality via an endovascular repair of extensive TAAAs (1). Materials and Methods: We compared the current hospital charges of endovascular and surgical repair of extensive TAAAs, also provided a cost analysis of health care charges resulting from paraplegia in the United States, and determined the prevalence of extensive TAAAs found yearly during autopsies in the U.S. Based on the figures gathered and the frequency of Thoracic Aortic Aneurysms per year, we were able to calculate the nationwide inpatient hospital charges, the total average expenses affected by paraplegia during the first 12 months after the repair, the total average expenses after paraplegia for each subsequent year, mortality rate at 30 days and one year, and the number of extensive TAAAs ruptures. Results: The current nationwide inpatient hospital charges for type II or III TAAA repair cost $12484324 and $37612665 for endovascular repair and surgical repair respectively, and the total average expenses for patients affected by paraplegia during the first 12-month were $4882291 and $23179110 after endovascular repair and surgical repair respectively. The nationwide average expense after 10 years for patients undergoing surgical repair and affected by paraplegia is $33421910 and $6,316,183 for patients undergoing endovascular repair. Moreover, 55 patients with a type II or type III TAAA died after 30 days, and 100 after 1 year. The potential risk of type II or III TAAA ruptures is totally 1637 in a year. Conclusions: Major economic impacts of type II or III TAAA repairs in the United States have been identified. An endovascular repair excluding spinal cord injury and mortality with the same average costs as present endovascular treatments makes it possible to save at least $53189742 after one year, 100 lives of operated patients would be saved after one year, and 1637 type II and III TAAA ruptures would be avoided yearly.

Background: Thrombosis is the most common complication during cardiac catheterization via femoral artery access. Alongside heparinization, fibrinolytic therapy is recommended if there are signs of ischemia in the lower extremity. Objectives: Given the paucity of data in the existing literature on streptokinase (SK) therapy in pediatrics, we designed this study to assess the efficacy of SK in pediatric patients with diagnosed femoral artery thrombosis following cardiac catheterization. Patients and Methods: The study population initially consisted of 1788 pediatric patients who underwent cardiac catheterization via the femoral artery access. Diminished or absent pulses in the lower extremity were detected in 123 patients, 45 of whom (2.5% of 1788) required treatment and were therefore considered for the next stage of study. Treatment was comprised of post-procedural intravenous heparin, either 50 U/kg/Q4h or 10 - 20 U/kg/h continuously. After heparinization for 24 hours, if the pulse of the affected extremity was not palpable, heparin therapy was continued (heparin-treated group, n = 28), and if the symptoms of femoral artery ischemia were persistent, heparin was discontinued and intravenous SK with a loading dose of 2000 U/kg over 20 - 30 minutes was commenced (SK-treated group, n =17). Results: In the presence of pulselessness in the lower extremity, a maintenance dose of SK (1000 U/kg/h, during 1 - 24 hours) was intravenously administered. Regarding the return of the pulses post-therapeutically, normal and weak/absent pulses were detected in seven (25.2%) and 21 (74.8%) of the 28 patients, respectively, in the heparin-treated group (P value < 0.001), whereas normal and weak/absent pulses were detected in 15 (88.2%) and two (11.8%) of the 17 patients, respectively, in the SK-treated group (P value < 0.001). Conclusions: Our findings demonstrated a high success rate and a low complication rate for systemic SK therapy in femoral artery thrombosis after catheterization.

Background: The treatment of an occluded saphenous vein graft (SVG) with percutaneous coronary intervention may encounter major adverse cardiac events (MACE). MACE rates have been reduced significantly by using the embolic protection device (EPD). Objectives: The aim of this study was to clarify the risks and the benefits of embolic protection devices. Patients and Methods: In a prospective, non-randomized observational study, patients aged 33 to 85 years old who underwent elective percutaneous coronary intervention due to SVG stenosis at our tertiary care center were enrolled between 2009 and 2011. The incidence rates of adverse events, including MACE, were obtained during the patients' hospitalization and at 30-day and 6-month follow-up. MACE included death, Q-wave and non-Q-wave myocardial infarction, in-stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From 150 patients enrolled to the study, 128 (85.3%) patients underwent direct stenting and the rest underwent the EPD procedure. In-hospital MACE occurred in 17.2% of the patients in the direct stenting group versus only 9.1% in the EPD group (P = 0.530). MACE incidence was gradually increased at one and 6-month follow-up periods in the direct stenting group (19.5% and 21.9%, respectively), and remained unchanged in the EPD group (9.1% at six-month follow-up). Multivariate logistic regression model showed that the stenting procedure type could not predict early and midterm MACE with the presence of baseline characteristics as cofounders. Conclusions: Despite the considerable lower early and midterm MACE rates, numerically following the EPD procedure compared to direct stenting, the difference in the MACE rates between the two groups was not significant.

Background: Measuring cardiac markers in blood has been the main strategy for the diagnosis of acute myocardial infarction for nearly 50 years. Creatine kinase-MB (CK-MB) has been demonstrated to be a highly specific marker. Objectives: The present study aimed to assess the role of CK-MB changes following percutaneous coronary intervention (PCI) to predict one year outcomes of this procedure. Patients and Methods: This cohort study was conducted on 138 patients diagnosed with coronary artery disease who underwent PCI. Sixty-nine patients who had a CK-MB elevation ≥ 3 times upper limit of normal (ULN) post procedurally were considered as group I and 69 patients without cardiac enzyme rise after PCI were considered as the control group (group II). The composite end point of major adverse cardiac events (MACE) during one year was assessed by telephone follow-up or presentation at clinical visiting, and compared between the two groups. The MACE was defined as the appearance of at least one of the following events: mortality, repeated revascularization procedures, myocardial infarction, or cerebrovascular events. Results: Although one year mortality in the group I was 4 (5.8%), about two times greater than the other group 2 (2.9%), the difference was not significantly discrepant (P = 0.57). Moreover, 8 (11.6%) of patients in group I experienced one year MACE, while this rate in the other group was 4 (5.8%), with insignificant difference (P = 0.22). In group I, one case experienced coronary artery bypass surgery, one, exhibited cerebrovascular disease and one reported ST segment elevation myocardial infarction (STEMI), while two patients in the other group were suspicious of having non-ST segment elevation myocardial infarction (NSTEMI) and candidates for repeated PCI. Multivariate analysis revealed that increased post-procedural CK-MB ≥ 3 times UNL could not predict long-term MACE in patients who underwent selective PCI. Area under the curve (AUC) for predicting one year MACE was 0.593 (95% CI: 0.397 - 0.788), indicating inappropriate accuracy for this biomarker (P = 0.290). Conclusions: It seems that CK-MB ≥ 3 times ULN within 24 hours after PCI cannot independently predict one year MACE in patients undergoing PCI.

A 48-year-old male with a history of secundum type atrial septal defect (ASD) closure in childhood presented to our outpatient clinic complaining of palpitation for six months. Interestingly, transthoracic and transesophageal echocardiography exams showed an undiagnosed partially unroofed coronary sinus associated with persistent left superior vena cava (LSVC) and Cor triatriatum.