Background: Sarcopenia is a predictor of mortality in multiple conditions but the potential prognostic value of indices of sarcopenia in pulmonary hypertension (PH) is not clarified. The aim of this study was to determine if there is an association between CT scan-measured pectoralis muscle area (PMA) and density (PMD) and adverse clinical outcomes in patients with PH.
Methods: In a cross-sectional study, medical records of PH patients (clinical class I and IV) referred to Rajaie Cardiovascular Center from March 2016 to March 2021 were retrospectively screened. CT scan-measured PMA and PMD were compared between survivors and non-survivors in addition to blood biomarkers and right heart catheterization variables. A binary logistic regression analysis was performed to determine the potential predictors of mortality.
Results: A total of 45 patients with PH (34 patients in survivor and 11 in non-survivor group) were included for data analysis. PMA was not significantly different between the two groups (p=0.124) whereas difference of PMD measures was weakly significant between survivors and non survivors (survivor: 45 HU (25.8-51.3), non-survivors: 31 HU (23-36); p=0.062)). In logistic regression analysis, none of the sarcopenia indices could predict mortality (p>0.05), although phosphodiesterase-5 (PDE-5) inhibitors, right atrial pressure (RAP), and systemic arterial oxygen saturation could serve as potential predictors (p<0.05).
Conclusion: Although CT scan-measured area and density of pectoralis muscle showed a weak correlation with prognosis of PH, there is a possibility that these factors could serve as potential markers for mortality in patients with idiopathic and chronic thromboembolic PH. Further confirmation is required through future studies with larger sample sizes.

Background: Adopting healthy nutritional behavior in patients with Heart Failure (HF) can play a crucial role in controlling symptoms of the disease. To develop effective interventions, it is recommended to recognize significant determinants of nutritional behavior based on theoretical frameworks in behavioral sciences and utilize valid instruments. The aim of this study was to develop and validate measurement tools for assessing the determinants of nutritional behavior among patients with HF based on the Theory of Planned Behavior (TPB) variables.

Methods: In this psychometrics study, a preliminary instrument based on the TPB with five subscales was created. Additionally, an instrument for measuring the nutritional behavior of HF patients was developed. The face validity and content validity of the instruments were assessed using both quantitative and qualitative methods. The factor structure of the instrument for assessing TPB variables was examined through Exploratory Factor Analysis (EFA) using a sample of 330 patients with HF. Furthermore, the reliability of the instruments was evaluated.

Results: In the stages of face validity and content validity assessment, 13 items were removed from the TBP instrument, and 14 items were modified in the two instruments. The EFA revealed that the 12 items of the TPB variables could be classified into 4 subscales, namely behavioral intention, attitude, and perceived behavioral control. The results of the EFA indicated that the Kaiser-Meyer-Olkin and Bartlett’s test of sphericity of the instrument were acceptable. These factors accounted for 87.03% of the variance. The TPB instrument subscales demonstrated acceptable levels of reliability, as indicated by Cronbach's alpha. Both instruments had acceptable levels of intraclass correlation coefficient.

Conclusions: The results showed that the developed instruments were two valid and reliable tools for assessing the determinants of adopting nutritional behavior among patients with HF, utilizing TPB variables. These instruments can be used in conducting needs assessments and developing education intervention efforts for patients with HF.

Background: A sinus venous atrial septal defect (SVASD) is a type of congenital heart defect that predominantly involves an opening between the Superior Vena Cava (SVC) and the Right Upper Pulmonary Vein (RUPV). Surgical closure of SVASD has been the standard treatment; however, the surgical closure of SVASD is far more complex than mere ASD secundum reconstruction, and complications are more likely. Transcatheter closure of SVASD is an emerging alternative for surgical repair.

Methods: We report five cases of successful transcatheter closure of SVASD and one case of failure that required surgical intervention. All patients underwent pre-procedure Computed Tomography Angiography (CTA) to determine the size and location of the defect and the optimal stent size and position. The SVC stenting was performed using balloon-expandable stents, followed by RUPV angioplasty if needed.

Results:  Final angiograms and pressure measurements in the SVC, RUPV, and Right Atrium (RA) confirmed the absence of residual shunt and pulmonary venous obstruction. One patient experienced stent migration to the pulmonary artery, which necessitated surgical retrieval and defect closure.

Conclusion: The balloon expansion test is not mandatory before stent implantation, as in the case of RUPV obstruction, its flow could be reestablished by ballooning and/or stent implantation within the RUPV with a mild residual shunt which might resolve spontaneously.

Background and objectives: Atrial Fibrillation (AF) is the most prevalent persistent arrhythmia with a great burden on people’s health and society. Due to associations between psychological factors and AF in previous studies, this study was conducted to investigate the association between perceived stress and arrhythmia.

Methods: In this case-control study, participants were recruited from the outpatient clinic of Rajaie Cardiovascular, Medical and Research Center in Tehran, Iran, between May 2021 and September 2021 based on eligible criteria. Data were collected through face-to-face interviews by trained research nurses using the appropriate checklists. The stress level of participants was evaluated using the Perceived Stress Scale (PSS). Data were analyzed by Chi-square, independent T-test, and logistic regression model in SPSS 16.

Results: One hundred fifty-five cases with arrhythmia and 144 controls were recruited for this study. The mean score of the perceived stress was 30.6 in cases and 25.07 in controls (P< 0.001). Stress-related symptoms including palpitation and chest discomfort were more common in patients with arrhythmia than healthy controls (P = 0.015 and P< 0.001 respectively). The risk of arrhythmia was independently associated with sex, diabetes mellitus, dyslipidemia, hypothyroidism, cardiomyopathy, concentration difficulty, chest discomfort, and stress score in the multivariate logistic regression model.

Interpretation and conclusions: The results of this study demonstrate that AF arrhythmia is strongly associated with psychological stress and higher perceived stress scores. Interventions targeting reducing stress in those who are at high risk of developing AF are beneficial.

Background: Heart transplantation has emerged as the preferred treatment for selected individuals with advanced heart failure. However, the outcomes and complications of this procedure have not been evaluated thoroughly among the Iranian population. In the present study, we aimed to provide a comprehensive understanding of the epidemiological characteristics of patients who had HT, with a focus on indications for HT, early and late complications, mortality causes, and survival rate.

Methods: In this retrospective cohort study, we included all patients aged ³18 years who underwent HT from July 2013 up to June 2023 at academic hospitals at Shiraz University of Medical Sciences. A questionnaire of several variables was completed for each patient by reviewing medical records. The following outcomes were collected for the first 10 years after HT surgery: (1) mortality/survival: the incidence of death, cause of death, and length of survival; (2) rejection: the incidence of rejection, time, and type of rejection; and (3) the incidence of early and late post-transplant complications. 1-year, 2-year, and 10-year survival was reported using Kaplan-Meier method. Multivariate relation with survival was evaluated by Cox regression analysis.

Results: 75 patients underwent Heart Transplant operation, among which, 48 were male and 27 were female. The most common underlying cause of Heart Transplant was dilated Cardiomyopathy accounting for 85.3% of surgeries. Following the surgery, fifteen (23.8%) patients had evidence of transplant rejection. Overall mortality was 29 deaths, 19 of which were male and 10 were female. Twelve patients (15.8%) died in the operating room and the overall survival of our patients was 129.41±14.94 months. By excluding the 12 in-OR expired patients, the survival rates at 1 year, 2 years, and 10 years improved to 80.7%, 71.1%, and 68.3%, respectively.

Conclusions: Overall, the findings of this study provide valuable insights into the demographic and clinical characteristics of patients who undergo HT, as well as their post-transplant outcomes. Additionally, our findings will contribute to the current body of knowledge on pre-heart transplant risk assessment and patient selection, as well as early post-heart transplant diagnosis and management of significant complications.

Background: Infective endocarditis (IE) uncommonly happens right-sided. Furthermore, Streptococcus agalactiae rarely causes IE, in which only 2-9% of bacteremia cases manifest as endocarditis. 

Case presentation: A 30-year-old Lebanese woman came to the emergency room (ER) with a high-grade fever and chills. Blood tests were drawn, urine analysis showed leukocytes in urine, and treatment for urinary tract infection was started accordingly. The patient was hospitalized three days later and transferred to the intensive care unit (ICU); severe right-sided cardiomegaly, flailed tricuspid leaflets with ruptured chordae, and large coaptation deflect were discovered during echocardiography. She was diagnosed with Streptococcus agalactiae right-sided infective endocarditis and underwent tricuspid valvular replacement. Unfortunately, the patient died after suffering from acute decompensated heart failure. 

Conclusion: This is an unusual S. agalactiae right-sided infective endocarditis case found in Lebanon, in which definitive treatment for IE caused by this agent is still limited.

Background: Pregnancy in pulmonary hypertensive female patients is strongly contraindicated because of the high mortality rate according to physiological changes, especially in peri- and postpartum periods, and in case of occurrence, termination at an early stage is recommended. Therefore, our experience with continued pregnancies in patients with pulmonary hypertension are scarce.

Case presentation: This case report presents a young woman diagnosed with multiple bilateral pulmonary hydatid cysts and right ventricular hydatid cyst, who underwent surgical and pharmacologic treatments, but developed pulmonary hypertension due to pulmonary artery obstruction eight years after. According to the unsuitable condition of the patient for surgery, she was a candidate for medical therapy, including Tadalafil, Bosentan, and Eplerenone. After 3 years, despite the advice to avoid pregnancy, the patient got pregnant and at 37 weeks underwent a successful emergent cesarean section due to maternal dyspnea and tachycardia.

Conclusions: We believe that prompt treatment and regular follow-ups in a tertiary care center with a multidisciplinary approach would be crucial in the management of pulmonary hypertensive patients who get pregnant.

Infective endocarditis (IE) is an under-recognized cause of fever that is often missed in preliminary evaluation. This may stem from a lack of vigilance towards IE and using empirical antibiotic therapy to treat fever. As a result, patients often present with complications of IE that warrant surgical intervention. We hereby discuss a case of IE that remained undiagnosed for 2 years, receiving short courses of oral antibiotic therapy for recurrent fever, ultimately developing heart failure due to valve perforation.

Syncope, characterized by transient loss of consciousness, is among the most common reasons for emergency department visits worldwide and can be categorized into reflex syncope, orthostatic hypotension, and cardiac syncope. Situational syncope as one of the subtypes of reflex syncope is much less investigated than other types. Herein, we report three patients presented to the syncope unit of Tehran Heart Center with unusual situational syncope triggers, in addition to their diagnosis tools and treatment of them. The first case was a 62-year-old woman with five syncopal episodes in the last two years, all of which were at the airport and during the airplane take-off. With the prescription of midodrine before the flights, no further syncope occurred. The second was an 18-year-old man with two syncope episodes, both of which were after marijuana smoking. He was advised to quit smoking marijuana and no syncope episode was recorded in the one-year follow-up. The last case was a 42-year-old heavy-smoker man with a complaint of several syncopal episodes after bursting coughs. After the failure of cough suppressor medications, he was cured with gabapentin. In conclusion, due to the complicated nature of syncope diagnosis in some cases, rare syncope triggers should always be taken into consideration by physicians in the history taking of patients with unexplained syncope.

Gallbladder and biliary tract diseases may manifest as cardiac symptoms, ischemic ECG changes, and arrhythmias. Although rare, bradyarrhythmia cases induced by cardiobiliary reflex have been linked to acute cholecystitis. This case emphasizes the cardiobiliary reflex as a possible cause of bradyarrhythmia in patients with gallbladder and biliary tract diseases . 

Background: In-stent restenosis (ISR) following percutaneous coronary intervention (PCI) is an unwanted complication in some patients. The etiology is multifactorial, and identifying these factors may help improve long-term outcomes after PCI.

Case summary: We hereby describe two cases of recurrent ISR; case 1 describes the techniques of PCI used over 17 years to manage recurrent ISR of Left Main bifurcation disease, while case 2 highlights the role of coronary artery bypass grafting (CABG) as a treatment modality for recurrent ISR of the right coronary artery.

Discussion: Management of post-PCI recurrent ISR has witnessed multiple advancements over the past decade. Newer technologies like intravascular imaging, plaque or calcium modification techniques, and drug-eluting balloons enable effective management of recurrent ISR.  This article describes possible risk factors for recurrent ISR and discusses various treatment strategies for its management.