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Heart Jo
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According to the ruling of the Medical Sciences Publications Commission No. 14313-80/10/1 and 36914-85/2/10 signed by the Minister of Health and Medical Education and the Head of the Medical Sciences Publications Commission of the Islamic Republic of Iran, this journal has been granted accreditation as a scientific-research journal. This Journal is indexed in the Scientific Information Database (WWW.SID.IR) and IMEMR and Index COPERNICUS, SCOPUS, CINAHL and Google Scholar.
ISSN: 1735-7306
http://www.sid.ir/
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OFFICIAL QUARTERLY PUBLICATION OF THE IRANIAN HEART ASSOCIATION
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Executive Board:
Chairman: Editor-in-Chief: Executive Manager: Feridoun Noohi, MD A. Hussein Tabatabaei, MD Majid Maleki, MD
Technical Editors: Associate Editors: Assistant Manager: Farshad Amouzadeh, MA Rasoul Azarfarin, MD Shahin Shrani, MD
Hooman Bakhshandeh, MD Shabnam Madadi, MD Reza Golpira, MD
Local Editorial Board: Abdi S. Gholampour Dehaki M. Maleki M. Peighambari M. M. Ahmadi H. Hagh Azali M. Mandegar M. H. Pezeshkian M.
Alizadeh Ghavidel A. R. Haghjoo M. Mehranpour M. Poorhosseini HR
Alizadeh Sani, Z Haj Sheikholeslami F. Mohagheghi A. Pourmoghaddas M. Aminian B. Haji Zeinali AM. Mohebbi A. Radpour M.
Arefi H. Hakim H. Mojtahedzadeh S. Sadeghi M.
Azarfarin R. Handjani A. M. Momtahen M. Sadeghpour Tabaee A. Azarnik H. Hashemi J. Mortezaeian H. Sadr Ameli M. A.
Baghezadeh A. Hashemian M. Mostafavi A. Sadeghpour A.
Baharestani B. Heidarpour A. Motamedi M. R. Sattarzadeh R. Bakhshankdeh H. Hosseini K. Nabavizadeh Rafsanjani F. Shahmohammadi A.
Bassiri H. Hosseini S. Navabi M. A. Shakibi J.
Bolourian A. Javidi D. Nazeri I. Shirani SH. Eslami M. Jebbeli M Nematipour E. Tabatabaei A. H.
Farasatkish R. Kalantar Motamedi M. H. Nikdoost F. Tabatabaei M. B.
Firouzabadi H. Karimi A. Nozari Y. Yousefi A.A. Firouzi A. Kazemi Saleh D. Ojaghi Haghigi S. Z. Youssefnia M. A.
Firouzi I. Kamal hedayat D. Noohi F. Vahedian J.
Ghaffari Nejad M. H. Kiavar M. Omrani G. Zavarehee A. Ghasemi M. Madadi Sh. Oraii S. Zand parsa A.F.
International Editorial Consultants: Alipour M. USA Karim S. Indonesia Pavie A. France
Anderson D. UK Khaghani A. UK Qureshi S. A. UK Bagir R. USA Koolen J. Netherlands Razavi M. USA
Bellosillo A. Phillipines Kranig W. Germany Robin J. France
Davis W. UK Kusmana D. Indonesia Sadeghi A. USA Deutsch M. Austria M Samuel. India Samad A. Pakistan
Djavan S. Austria Malek J. USA Sheikh S. Pakistan
Domanig E. Austria Marco J. France Sheikhzadeh A. Germany Dorosti K. USA Mee R. USA Shenasa M. USA
Elliott M. UK Mirhoseini M. USA Siddiqui H. India
Estafanous F.G. USA Monga M. S. Pakistan Sloman G. Australia Foale R. UK Moosivand T. Canada Smith W. M. New Zealand
Gandjbakhch I. France Moten M. USA Tajik A. J. USA
Jahangiri M. UK Nagamia H. USA Tynan M. UK Jazayeri M.R. USA Otto A. Turkey Wolner E. Austria
Contributing Editors of This Issue: Abdi S. Jebbeli M Mandegar M. H. Peighambari M. M.
Azarfarin, R. Kamal hedayat D. Mohebbi A. Sadr Ameli M. A. Bassiri H.A. Madadi, Sh. Noohi F. Shirani, Sh.
Hosseini S. Maleki M. Omrani G.R. Tabatabaei A. H.
Technical Typist: F. Ghomi
Secretary: A. Beheshti
Address: Iranian Heart Association: P.O. Box: 15745-1341, Tehran, I.R. Iran. Tel: (009821) 22048174, Fax: (009821)
22048174
E-mail: [email protected]
mailto:[email protected]
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EDITORIAL
In the Name of God, the Most Beneficent, the Most Merciful
Dear colleagues and friends,
We are delighted to present to you Volume 17, Number 2 (Summer, 2016) issue of The
Iranian Heart Journal, which contains some interesting new studies and case reports in the
domains of cardiovascular medicine and surgery from our colleagues across Iran.
The Iranian Heart Journal is indexed in the Scientific Information Database (WWW.SID.IR),
IMEMR, Index Copernicus, Scopus, and CINAHL, thereby facilitating access to published
literature. There is no doubt, however, that our journal requires your opinions, ideas, and
constructive criticism in order to accomplish its main objective of disseminating cutting-edge
medical knowledge.
As ever before, we continue to look forward to receiving your latest research and cases.
Yours truly,
A. Hussein Tabatabaei, MD F. Noohi, MD
Editor-in-Chief, Chairman,
The Iranian Heart Journal The Iranian Heart Journal
http://www.sid.ir/
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Volume 17, Number 2
Summer, 2016
CONTENTS:
Page
ORIGINAL ARTICLES: CLINICAL SCIENCE
Assessment of Pulmonary Regurgitation Severity in Tetralogy of Fallot Total Correction: Comparison
Between Doppler Echocardiography and Cardiac MRI
Majid Kyavar, MD; Reyhaneh Shabani, MD; Hooman Bakhshandeh Abkenar, MD; Peyman Keyhanvar, MD;
Shabnam Madadi, MD
6-11
Left and Right Approach Atrioventricular Junctional Ablation in Patients With Permanent Atrial
Fibrillation
Mona Kia, MD; Seyed Abdolhussein Tabatabaei, MD; Ata Allah Bagherzadeh, MD; Farahnaz Nikdoust, MD
12-17
Cardiac Involvement and Echocardiographic Characteristics in Rheumatoid Arthritis
Farahnaz Nikdoust, MD; Reza Zangeneh, MD; Seyed Abdolhussein Tabatabaei, MD
18-24
256-Slice Computed Tomography in the Diagnosis of Coronary Artery Disease in Patients Presenting
With Aortic Dissection Between 2011 and 2014 and the Influence of Concomitant Coronary Artery
Disease on in-Hospital Mortality
Hossein Azarnik, MD; Majid Kyavar, MD; Shabnam Madadi, MD; Nasim Naderi, MD; Farzad Kamali, MD; Amir Khosropour, MD; Javad Robat Sarpoushi, MD; Armin Marashizadeh, MD
25-29
Ten Years of Experience in a Tertiary Center in Pulmonary Valvuloplasty in Pediatric and Adult
Populations
Ata Firouzi, MD; Sakineh Ahmadzadeh, MD; Mohammadreza Bayanati, MD; Parham Sadeghipour, MD;
Reza Kiani, MD; Hamid Reza Sanati, MD; Negar Salehi, MD; Farshad Shakerian, MD; Ali Zahedmehr, MD;
Leila Shokrian, MD
30-37
Is There Concordance Between CMR and Echocardiography in Assessing Aortic Stenosis Severity?
Sepideh Jafari Naeini, MD; Mozhgan Parsaee, MD; Shabnam Madadi, MD; Zahra Hosseini, MD
38-43
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CONTENTS:
ORIGINAL ARTICLES: CLINICAL SCIENCE
Page
CASE REPORT
Double Left Anterior Descending Artery Arising From the Left and Right Coronary Arteries in a
Patient Undergoing Preoperative Evaluation Before Elective Noncardiac Surgery
Seyed Kianoosh Hosseini, MD; Masoud Fakhraei, MD; Siamak Khavandi, MD; Soheila Khavandi, MD
44-47
Patent Foramen Ovale: A Source of Emboli or an Innocent Bystander?
Ahmad Mirdamadi, MD; Mojgan Gharipour, MD; Seied Mahfar Arasteh, MD
48-52
INSTRUCTIONS FOR AUTHORS 53-56
FORTHCOMING MEETINGS 57-62
SUBSCRIPTION FORM 63-64
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Comparison between Cardiac MRI and Echocardiography for Pulmonary Regurgitation Assessment Kyavar M, et al.
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Original Article Comparison between Cardiac MRI and Echocardiography for Pulmonary Regurgitation Assessment Kyavar M, et al.
Assessment of Pulmonary Regurgitation Severity in Tetralogy of
Fallot Total Correction: Comparison Between Doppler
Echocardiography and Cardiac MRI
Majid Kyavar1, MD; Reyhaneh Shabani
1, MD;
Hooman Bakhshandeh Abkenar1, MD; Peyman Keyhanvar
1,2, MD;
Shabnam Madadi1* MD
ABSTRACT
Background: Pulmonary regurgitation is a common finding in patients after tetralogy of Fallot total
correction (TFTC). Right ventricular enlargement and dysfunction have been ascribed to
pulmonary insufficiency (PI), which is an important issue in the follow-up of patients with
TFTC. We sought to compare PI measured by echocardiography with data provided by
cardiac magnetic resonance imaging (CMR).
Methods: We studied 155 selected patients (91 male; median age = 25.65 y, range = 1555 y) after TFTC. To quantify the pulmonary regurgitant fraction (PRF) by CMR, we performed flow
velocity mapping. On Doppler echocardiography, the length, width, and localization of the
regurgitant flow, no-flow time, and pressure half-time were measured. The severity of PI on
echocardiography was categorized as nonsignificant and significant and was thereafter
compared to the data obtained by CMR.
Results: In all 155 patients, the measurement of the flow and volume was possible by CMR, and the
measurement of PI was possible by Doppler echocardiography. The mean PRF, as
determined by CMR, was 33% 16.4%. Pulmonary regurgitation has been reported to be a
causative factor in right ventricular volume enlargement. A PRF > 20% was considered
significant and was compared with echocardiographic parameters and also right ventricular
size and function and other indices resulted from CMR. The regression analysis showed a
significant correlation between PI severity on CMR and right ventricular enlargement on
MRI at end diastole (r = 0.746; P < 0.001) and also at end systole (r = 0.71; P < 0.05).
Conclusions: There was no significant correlation between right ventricular ejection fraction and PI
severity on CMR (r=0.553; P=0.45). On echocardiography, the semiquantitative
estimation of pulmonary regurgitation showed that there were 26 patients with mild-to-
moderate PI and 99 patients with severe PI. A right ventricular end-diastolic volume index
(RVEDVI) of 121 mL/m was 87% sensitive and 54% specific for severe PI, and an
RVEDVI of 180 mL/m was 90% specific for severe PI. (Iranian Heart Journal 2016; 17(2):
6-11)
Keywords: Pulmonary regurgitation Cardiac MRI Echocardiography.
1 Department of Cardiology; Rajaie Cardiovascular, Medial, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, I.R. Iran.
Corresponding Author: Shabnam Madadi, MD
E-mail: [email protected] Tel: 09126961606
Received: August 8, 2015 Accepted: April 23, 2016
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Comparison between Cardiac MRI and Echocardiography for Pulmonary Regurgitation Assessment Kyavar M, et al.
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etralogy of Fallot (TOF) is the most
common cyanotic cardiac lesion, but it
is successfully manageable with
surgery. The surgical modality confers
successful intracardiac repair. In 1954,
Lillehei and Varco performed the first repair
of TOF by using parental cross-circulation at
the University of Minnesota. They closed a
ventricular septal defect and relieved right
ventricular outflow tract (RVOT) obstruction
under direct vision, but the procedure was
associated with a high mortality rate (200%).
In 1955, Kirklin performed the first successful
repair of TOF with a pump oxygenator at the
Mayo Clinic. Nowadays, the cardiopulmonary
bypass machine is drawn upon to accomplish
the complete repair of TOF. The aim of the
surgical repair of TOF is to create a near-
physiological hemodynamic situation, which
is achieved by the closure of the ventricular
septal defect and by the relief of RVOT
obstruction. Currently, the mortality of
tetralogy of Fallot total correction (TFTC) is
low, the long-term results are good, and most
of the patients reach adulthood.1,2
The
severity of pulmonary insufficiency (PI) has
been quantified via different modalities,
including the determination of regurgitant jet
length and width; however, these parameters
are highly dependent on the pressure gradient
between the pulmonary artery and the RV and
as such fail to constitute a very reliable index.
The assessment of the vena contracta width in
contrast with other valves is more difficult in
the pulmonary valve and cannot be deemed
very useful in the evaluation of PI severity. A
further validated methodand the current
gold standardfor the quantitative
noninvasive assessment of the pulmonary
regurgitant fraction (PRF) is cardiac magnetic
resonance imaging (CMR) using flow
velocity mapping (phase-encoded imaging).
This method provides systolic and diastolic
flow volumes through the pulmonary valve
and is able to quantify the PRF without
radiation exposure or contrast medium
administration.3-6
The purpose of the present study was to
compare the echocardiographic approach and
the quantitative approach of CMR flow
velocity mapping for the assessment of PI.
METHODS
Study Population The study protocol was approved by the local
ethics committee. We examined 155 selected
patients, comprising 91 male and 59 female
patients, who had undergone TFTC in
childhood or years earlier and referred to us
for routine follow-up visits. None of these
patients had pacemakers or implantable
cardioverter defibrillators. Claustrophobia and
poor echocardiography window were also
among the exclusion criteria. The median age
of the patients at the time of CMR study was
25.65 years (range=1555y). The echocardio-graphic assessment of pulmonary
regurgitation was performed within a period
of 14 days before CMR.
Cardiac Magnetic Resonance Imaging All CMR examinations were performed using
a 1.5-T Avanto (Siemens Medical Systems)
with an 18-channel phased-array coil. For the
assessment of regurgitation fraction phase
shift velocity, mapping was performed with a
flow-sensitive gradient-echo sequence.8-11
This method allows the calculation of flow
velocity and flow volume by the velocity-
dependent phase shift of the moving spins. A
perpendicular orientation (through plane) directly cranial to the pulmonary valve was
used to quantify flow volumes (TE/TR6/22
msec, flip angle = 35). The tolerated
deviation of perpendicular orientation was 15
maximum.12
Encoded velocity was 150 cm/s.
In the event of aliasing, encoded velocity was
increased in steps of 25 cm/s up to 350 cm/s.
For the assessment of end-systolic and end-
diastolic volumes of both ventricles, a cine-
MR sequence in the short-axis view and the
axial view without the navigator technique
was employed (flip angle = 30, matrix size =
128 256, and slice thickness = about 7 mm).
T
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Comparison between Cardiac MRI and Echocardiography for Pulmonary Regurgitation Assessment Kyavar M, et al.
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Cine-MR provides multiple slices that cover
the entire volume of both ventricles. By
manually tracing the endocardial contours of
the end-diastolic and end-systolic phases of
each slice, we found it possible to calculate
the volume and function of both ventricles.
The limits between RV blood pool from the
right atrium were identified by marking the
level of the atrioventricular valve in the RV 2-
chamber long-axis view and transferring these
marks to the short-axis views. RV
infundibulum was also included in RV
volume up to the pulmonary valve.13-14
Doppler Echocardiography
In all 155 patients, transthoracic
echocardiography was performed by
experienced echocardiologists within a period
of 14 days before CMR using a Vivid GE
system with a 3.5-MHz probe. Pulmonary
regurgitation was classified into 2 categories
(mild and moderate to severe), according to
the length and width of the regurgitant flow in
the color Doppler mode and pressure half-
time and no-flow time (NFT) on continuous
wave and pulsed-wave Doppler echocardio-
graphy.
Statistical Analysis
The values are expressed as medians (ranges)
or means (SDs). The correlations between
the different variables were determined with
ANOVA. The Pearson correlation was
subsequently used to assess the different
variables. The distribution of the PRF on
CMR among the echocardiographic
categories was depicted using box-plot
diagrams. The KruskalWallis test was
utilized to determine the degree of correlation
(P < 0.01 and P < 0.05). All groups were
compared with one another pair-wise using
the MannWhitney test. Calculations were
performed using the SPSS-PC statistics
software package.
RESULTS
In all 155 patients, the measurement of the
flow and volume was possible by CMR, and
the measurement of PI was possible by
Doppler echocardiography. The mean PRF, as
determined by CMR, was 33% 16.4%.
Pulmonary regurgitation has been reported to
be a causative factor in RV volume
enlargement. A PRF > 20% was considered
significant and was compared with the
echocardiographic parameters and also RV
size and function and the other indices
resulted from CMR. The regression analysis
exhibited a significant correlation between PI
severity on CMR and RV enlargement on
MRI at end diastole (r = 0.746; P < 0.001)
and also at end systole (r = 0.71; P < 0.05)
(Fig. 1).
Figure 1. Relationship between right ventricular volumes and the pulmonary insufficiency severity ROC curve
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Comparison between Cardiac MRI and Echocardiography for Pulmonary Regurgitation Assessment Kyavar M, et al.
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A right ventricular end-diastolic volume index
(RVEDVI) of 121 mL/m was 87% sensitive
and 54% specific for severe PI, and an
RVEDVI of 180 mL/m was 90% specific for
severe PI. A right ventricular end-systolic
volume index (RVESVI) of 66 mL/m was
88% sensitive and 42% specific for severe PI.
There was no significant correlation between
right ventricular ejection fraction (RVEF) and
PI severity on CMR (r = 0.553; P = 0.45).
Figure 2. Relationship between right ventricular ejection fraction and the pulmonary insufficiency severity ROC curve
An RV outflow tract size (by MRI in the
sagittal view) > 3.12 cm was 90% sensitive
and 49% specific for severe PI. On
echocardiography, the semiquantitative
estimation of pulmonary regurgitation
demonstrated that there were 26 patients with
mild-to-moderate PI (group 1) and 99 patients
with severe PI (group 2). An RVEDVI of 121
mL/m was 87% sensitive and 54% specific
for severe PI, and an RVEDVI of 180 mL/m
was 90% specific for severe PI. Additionally,
an RVESVI of 66 mL/m was 88% sensitive
and 42% specific for severe PI. There was no
significant correlation between RVEF and PI
severity on CMR (r = 0.553; P = 0.45).
There was also a relatively significant
correlation between the quantitative RV
function parameters as assessed by
echocardiography such as tricuspid annular
plane systolic excursion (TAPSE) and tissue
Doppler peak systolic velocity in systole (TDI
SM) and PI severity according to the
regression analysis (r=0.64 and 0.64; P=0.05).
Additionally, a TDI SM of 8.5 cm/sec was
65% sensitive and 62% specific for severe PI,
and a TAPSE of 15 cm was 85% sensitive and
47% specific for severe PI. Nonetheless, in
the eyeball assessment of RV function by
echocardiography, a relatively weak
correlation was present with PI severity
(r= 0.56).
Figure 3. Relationship between TDI SM and TAPSE and the PI severity ROC curve
TDI SM, Tissue Doppler peak systolic velocity in systole; TAPSE, Tricuspid annular plane systolic excursion; PI, Pulmonary insufficiency
Figure 4. Relationship between no-flow time (NFT) and the pulmonary insufficiency (PI) severity ROC curve
NFT, No-flow time; PI, Pulmonary insufficiency
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DISCUSSION
A reliable estimation of PI is one of the
central points in the follow-up of patients with
TFTC. CMR phase-contrast flow
measurement is the current gold standard for
determining the PRF.13-14
As much as the
accuracy of this modality has been shown in
several studies,1518
not only are there some
relative and absolute contraindications to this
modality but also it is very expensive and
time-consuming. Therefore, a Doppler
echocardiographic estimation of pulmonary
regurgitation is a basic procedure in follow-up
examinations. Although it is theoretically
possible to quantify pulmonary regurgitation
by echocardiography,9 the estimation of PI is
semiquantitative in routine clinical practice.
The present study demonstrated the
significance of Doppler echocardiography in
the assessment of PI in patients after TFTC.
Our results revealed that echocardiography
according to a pressure half-time < 60 msec
was able to predict significant PI depicted by
CMR as a PRF > 20% and that there was a
significant correlation between no-flow time
(> 94 msec) on echocardiography and PI
severity on MRI. In clinical practice,
however, it is high-degree pulmonary
regurgitation, its impairment of RV function,
and its volume overload that should be
recognized.16
Doppler echocardiography is,
therefore, considered a reliable diagnostic tool
in the assessment of PI in follow-up
examinations in patients after TFTC. There
was a significant correlation between the
echocardiographic assessment of RV function
and MRI-derived RVEF.
CONCLUSIONS
Pulmonary regurgitation is an important
prognostic parameter in patients after TFTC.
In the present study, Doppler
echocardiography was able to assess the
severity of PI with reasonable agreement with
CMR phase-contrast flow measurements. It is,
therefore, a reliable, cost-effective, and
readily available diagnostic tool for routine
follow-up examinations in these patients.
Acknowledgements
The authors gratefully acknowledge the
cardiac MRI section staff in Rajaie
Cardiovascular, Medical, and Research Center
and in particular Dr. Pour Ali Akbar and Ms.
Nafari.
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Atrioventricular Junctional Ablation in Atrial Fibrillation Kia M, et al.
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Original Article Running Title: Atrioventricular Junctional Ablation in Atrial Fibrillation Kia M, et al.
Left and Right Approach Atrioventricular Junctional
Ablation in Patients With Permanent Atrial Fibrillation
Mona Kia1, MD; Seyed Abdolhussein Tabatabaei
1, MD;
Ata Allah Bagherzadeh1*
, MD; Farahnaz Nikdoust1, MD
ABSTRACT
Background: Despite the clear beneficial effects of atrioventricular nodal ablation (AVNA) in atrial
fibrillation (AF), the differences in these effects between the 2 technical methods of
AVNAretrograde and antegrade approachesremain unclear. The present study aimed to
compare the outcome of these 2 AVNA approaches in AF.
Methods: This clinical trial was performed on 109 consecutive patients candidated for cardiac
resynchronization therapy (CRT) due to the presence of simultaneous heart failure and AF.
The eligible patients were randomly scheduled for CRT via left AVNA or CRT via right
AVNA or medical treatment approaches.
Results: No statistically significant differences were observed between the right (3.121.88) and
left (3.121.78) approaches of AVNA regarding a decrease in New York Heart Association
score as well as an increase in left ventricular ejection fraction (18.0%23.75% in the right
approach and 18.46%25.77% in the left approach). Although the severity of mitral
regurgitation significantly decreased following both CRT via the left AVNA approach and
CRT via the right AVNA approach, the reduction in the severity of mitral regurgitation was
more prominent in those treated by CRT via the right AVNA approach.
Conclusions: In reducing the severity of mitral regurgitation as well as femoral complications, right
AVNA was superior to left AVNA, while left AVNA was preferable to right AVNA
concerning the escape rate, procedure time, and radiofrequency rate. (Iranian Heart Journal
2016; 17(2):12-17)
Keywords: Atrial fibrillation Atrioventricular junctional ablation Cardiac resynchronization therapy
1 Department of Cardiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, I.R. Iran.
Corresponding Author: Ata Allah Bagherzadeh, MD
E-mail: atabzd@ gmail.com Tel: 09123115030
Received: October 12, 2015 Accepted: March 28, 2016
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Atrioventricular Junctional Ablation in Atrial Fibrillation Kia M, et al.
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espite the established efficacy of
cardiac resynchronization therapy
(CRT) in congestive heart failure due
to systolic dysfunction, the beneficial effects
of this technique in atrial fibrillation (AF) still
remain uncertain. According to the latest
European guidelines, CRT is beneficial in
patients with permanent AF with the same
indications of sinus rhythm (class IIa, level of
evidence: B) and atrioventricular junctional
ablation should be considered in cases of
incomplete biventricular pacing (class IIa,
level of evidence: B).1
The limited available evidence suggests the
favorable effects of CRT in the AF setting.
Initial reports showed the beneficial effects of
CRT on hemodynamic parameters at short-
term follow-up.2,3
Furthermore, recent studies
investigating the long-term effects of CRT in
AF have demonstrated improvements in New
York Heart Association (NYHA) functional
class, exercise capacity, left ventricular
ejection fraction (LVEF), and quality of
life.4-8
However, there is also some evidence
to suggest that CRT may not be as effective as
was previously reported for patients with AF
undergoing CRT.9-13
Several factors have
been cited for this observation. Firstly, AF
precludes the atrioventricular optimization of
CRT. Secondly, a high intrinsic ventricular
response leads to electrical fusion and reduces
biventricular pacing capture and,
consequently, cardiac output.14,15
Importantly,
randomized controlled clinical outcome trials
of CRT have almost always excluded patients
with AF. In this regard, current guidelines
from the American College of Cardiology/
American/ Heart Association/ Heart Rhythm
Society and the European Society of
Cardiology (class IIa, level of evidence: B)
endorse the use of CRT in patients suffering
from AF with LVEF 35% and ventricular
dyssynchrony.16-18
However, both guidelines
advise that atrioventricular nodal ablation
(AVNA) may be required to ensure complete
biventricular capture in patients with AF. This
approach can reduce mortality as well as
improve functional capacity and LV
functional status in patients with AF.19,20
Despite the clear beneficial effects of AVNA
in patients with AF, the differences in these
effects between the 2 technical methods of
AVNAretrograde and antegrade
approachesremain unclear. The present
study aimed to compare the outcome of these
2 AVNA approaches in AF.
METHODS
This clinical trial was performed on 109
consecutive patients candidated for CRT. The
inclusion criterion was the presence of
simultaneous heart failure and AF rhythm.
The exclusion criteria were comprised of a
history of receiving ablation therapy and
implantable cardioverter defibrillators or
pacemaker insertion.
On admission, the baseline dataincluding
demographics, medications, medical history,
duration of AF, and echocardiographic
parameterswere assessed and recorded. The
eligible patients were then randomly
scheduled for CRT via left AVNA (n = 32),
CRT via right AVNA (n = 26), and medical
treatment (n = 51). The study end point was to
compare the postprocedural outcome
including AVNA success rate, AF relapse,
and postoperative complicationsbetween
the 2 AVNA techniques.
For the statistical analyses, the results are
presented as means SDs for the quantitative
variables and were summarized by absolute
frequencies and percentages for the
categorical variables. Normality of data was
analyzed using the KolmogorovSmirnov
test. The categorical variables were compared
using the 2
test. The quantitative variables
were also compared using ANOVA or the
KruskalWallis H test. For the statistical
analyses, SPSS, version 16.0 for Windows
(SPSS Inc., Chicago, IL), was used. A
P0.05 was considered statistically
significant.
D
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RESULTS
The 3 groups were similar in terms of gender,
etiology of the disease (ischemic or
idiopathic), mean age, and QRS duration on
ECG (Table 1). There was also no difference
across the 3 groups in the baseline NYHA
score. However, after AVNA, the mean
NYHA score decreased significantly in CRT
via left AVNA (3.121.78) compared to
medical treatment (2.962.16), but no
difference was revealed in the mean NYHA
score between the 2 modalities of CRT via the
left and right approaches (Table 2). Also, the
mean LVEF was similar between the 3 groups
at baseline, but the post-treatment LVEF was
significantly high following CRT via the right
AVNA approach when compared to medical
treatment. In this regard, no difference was
found in the mean postoperative LVEF
between the 2 procedures of CRT via the left
and right approaches.
As is shown in Table 2, no differences were
found between the 3 groups in terms of LV
end-systolic and end-diastolic diameters
before and also after the treatments.
Regarding the severity of mitral regurgitation
(MR), no difference was revealed in
pretreatment MR severity across the 3 groups.
Although the severity of MR significantly
decreased following both CRT via the left and
right AVNA approaches, MR severity
reduction was more prominent in those
treated with CRT via the right AVNA
approach (Table 2).
There was no difference in total hospital stay
between the 2 groups treated with CRT via
the left and right AVNA approaches, but it
was significantly short in both groups when
compared to those treated medically.
Similarly, the mean biventricular pacing was
lower in both groups treated with CRT via left
AVNA and CRT via right AVNA than in the
medical treatment group, without difference
between the 2 former groups.
Table 1. Baseline characteristics of the study population
Item CRT, Left AVNA CRT, Right AVNA Medical Treatment P
Gender Male 24 (75.0%) 18 (69.2%) 33 (64.7%)
0.615 Female 8 (25.0%) 8 (30.8%) 18 (35.3%)
Etiology Ischemic 20 (62.5%) 16 (61.5%) 29 (59.6%)
0.856 Idiopathic 12 (37.5%) 10 (38.5%) 22 (43.1%)
Age, y 56.12 (14.70) 58.23 14.39 54.67 (15.21) 0.609
QRS duration, msec 161.69 (23.65) 156.69 (21.04) 153.98 (20.86) 0.295
AVNA, Atrioventricular nodal ablation
Table 2. Clinical and echocardiographic parameters before and after treatment
Item CRT, Left AVNA CRT, Right AVNA Medical Treatment P
NYHA Class Before 3.12 (0.49) 3.12 (0.43) 2.96 (0.53) 0.248
After 1.78 (0.79) 1.88 (0.52) 2.16 (0.64) 0.036
LVEF Before 18.05 (5.12) 18.46 (5.29) 18.43 (5.61) 0.946
After 23.75 (7.30) 25.77 (4.40) 22.30 (4.76) 0.030
LVEDD Before 6.60 (0.58) 6.95 (0.57) 6.72 (0.71) 0.130
After 8.13 (10.21) 6.44 (0.61) 7.54 (8.09) 0.712
LVESD Before 5.85 (0.63) 5.91 0.74 5.86 (0.76) 0.948
After 5.48 (0.58) 5.53 0.67 5.54 (0.69) 0.921
Severe MR Before 13 (40.6%) 6 (23.1%) 16 (31.4%) 0.198
After 1 (3.1%) 1 (3.8%) 5 (9.8%) 0.044
NYHA, New York Heart Association; LVEF, Left ventricular ejection fraction; LVEDD, Left ventricular end-diastolic diameter; LVESD, Left ventricular end-systolic diameter; MR, Mitral regurgitation
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The mean (SD) procedure time was 20.81
( 4.86) minutes in the left AVNA group and
26.15 ( 8.31) minutes in the right AVNA
group, which was significantly lower in the
former group (P=0.003). There was no
difference in the rate of femoral artery
complications between the left AVNA group
and the right AVNA group (9.4% vs. 3.8%;
P=0.620). The mean radiofrequency rate was
significantly lower in the left AVNA group
than in the other group (1.44 [ 0.72] vs. 1.92
[ 0.69]; P = 0.011). The mean escape rate
was also lower in the left AVNA group than
in the right AVNA group (23.22 [ 9.66] vs.
34.08 [ 8.76]; P = 0.001).
DISCUSSION
Reviewing the literature documents this fact
that almost all studies on the effects of CRT
on AF management have mainly focused on
comparing this approach with and without
concurrent AVNA and thus no study has been
published to compare the retrograde and
antegrade AVNA procedures. Therefore, we
tried to compare the procedural outcomes
including functional status, echocardiographic
parameters, and post-ablation complications.
Our results showed no differences between
left and right AVNA regarding improvement
in function class, LV systolic function, and
LV diameters. However, compared to medical
treatment, the effectiveness of the 2 AVNA-
based procedures was demonstrated. Be that
as it may, as regards MR severity and femoral
complications, right AVNA was superior to
left AVNA, while left AVNA was preferable
to right AVNA in terms of escape rate,
procedure time, and radiofrequency rate.
Thus, we think that the superiority of one
technique to another cannot be concluded
concretely based on the findings; this
necessitates further assessments with long-
term follow-ups.
As has been previously shown, most previous
studies have highlighted the effects of AVNA
on cardiac performance indices. In a previous
study, the ablation of the AV node was
associated with a reduction in all-cause
mortality.21
In a systematic review, the
response rate to CRT in patients who
underwent AVNA was significantly higher
than that in those not scheduled for AVNA.22
In another study, although mortality rate was
similar between the group undergoing CRT
via AVNA and the group with sinus rhythm,
cardiac-related mortality was considerably
lower in the former group (8.1% vs. 11.1%).23
In another study, AF response to CRT via
AVNA was significantly higher than that in
those with sinus rhythm.24
In a study by
Himmel et al.,25
function class, LVEF, and
left ventricular end-diastolic diameter all
improved following CRT via AVNA. Finally,
in a survey by Brignole et al.,26
heart failure
deterioration and its concomitant
hospitalization in the groups treated with and
without CRT were 11% and 26%,
respectively, with a significant difference.
In conclusion, despite the significant
therapeutic effects of CRT via AVNA on
functional capacity and echocardiographic
indices, the effects of the left and right AVNA
procedures are similar in the short term.
However, right AVNA was superior in the
improvement of MR severity as well as
postoperative femoral complications, while
procedure time, radiofrequency rate, and
escape rate were all lower in the left AVNA
procedure.
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Original Article Running Title: Echocardiography and Rheumatoid Arthritis Nikdoust F, et al.
Cardiac Involvement and Echocardiographic
Characteristics in Rheumatoid Arthritis
Farahnaz Nikdoust1, MD; Reza Zangeneh
1, MD;
Seyed Abdolhussein Tabatabaei1*, MD
ABSTRACT
Background: As the cardiac function in patients with rheumatoid arthritis (RA) has not been well
studied via echocardiography yet, we aimed to determine cardiac involvement and
echocardiographic features in patients with RA of at least 5 years duration who referred to
our hospital between 2012 and 2014.
Methods: In this cross-sectional study, patients with RA were compared to healthy controls in terms of the cardiac function via Doppler echocardiography. After collecting the clinical and
demographic data in both groups, we performed Doppler echocardiography for both groups
to evaluate ventricular function and dimensions as well as valvular function.
Results: Forty-six patients with RA (mean age = 51.3 y) were compared to 48 healthy controls
(mean age = 50.2 y). The body mass index was significantly higher in the patients with RA
(P = 0.01). Left ventricular ejection fraction was significantly lower in the case group
(P
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Echocardiography and Rheumatoid Arthritis Nikdoust F, et al.
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disease,5 valvular heart disease,
6 aortitis,
7
myocarditis,8 and pulmonary hypertension
9
are the instances of cardiovascular
involvement in RA. However, cardiac
involvement in RA is not always symptomatic
and sometimes has no apparent feature.10,11
Therefore, data on cardiovascular
involvement in RA are limited and many
aspects of cardiovascular involvement have
yet to be explored.
Postmortem studies have shown the presence
of myocardial and endocardial involvement in
patients with RA.12
Meanwhile, heart failure
in the context of RA results from systolic or
diastolic dysfunction or a combination of
both.13
Diastolic left ventricular dysfunction
can be related to structural heart abnormalities
such as the hypertrophy of interstitial fibrosis
and, therefore, abnormal myocyte relaxation
due to ischemia.14
Many noninvasive
modalities like Doppler echocardiography, M-
mode color Doppler echocardiography, tissue
Doppler imaging, magnetic resonance
imaging, and radionuclide ventriculography
can be drawn upon to assess the systolic and
diastolic functions of the heart.15,16
Although transthoracic Doppler
echocardiography has been employed to
discover cardiac involvement in many other
autoimmune diseases, there is limited
evidence regarding the echocardiographic
features of patients with RA. It is obvious that
the use of this modality can help to recognize
RA cases with subclinical ventricular
dysfunction. Accordingly, we aimed to
investigate the echocardiographic
characteristics of patients with RA of at least
5 years duration who referred to our
institution and to compare the results with
those of healthy controls.
METHODS
In this study, we enrolled patients with RA of
at least 5 years duration who presented to the
Rheumatology Clinic of Dr. Shariati Hospital,
Tehran University of Medical Sciences,
Tehran, Iran. We excluded patients with a
history of cardiovascular disease. Age- and
sex-matched healthy controls were selected
from the hospital staff. All participants signed
an informed consent before enrolment in the
study, and the study protocol was approved
by the Board of Research and Ethics
Committee of Tehran University of Medical
Sciences.
Following admission, a detailed history was
obtained from the patients and clinical
examinations were performed by the
physician in charge. Demographic variables
comprising age, sex, height, and weight
were recorded. The patients and controls were
also checked for the presence of classic
cardiovascular risk factors such as
hypertension, diabetes mellitus, dyslipidemia,
smoking, and family history of premature
coronary artery disease. Clinical parameters
encompassed heart rate, systolic and diastolic
blood pressures, presenting symptoms, history
of myocardial infarction or stroke, and
congestive cardiac failure.
After collecting the baseline demographic and
clinical data, we evaluated all participants via
transthoracic echocardiography and tissue
Doppler imaging, using GE Vivid 7
Dimensions ultrasound system (GE
Healthcare, Milwaukee, WI). All
echocardiographic evaluations were
performed by a cardiologist, who was blinded
to the study protocol. Valvular regurgitation
severity was assessed via echocardiography
and was scored 0 as none or trivial, 1 as mild,
2 as moderate, 3 as moderate to severe, and 4
as severe regurgitation. Left ventricular size
was assessed by end-systolic and end-
diastolic diameters in the parasternal long-
axis view and end-systolic and end-diastolic
volumes in the apical 4-chamber view. Left
ventricular systolic function and ejection
fraction were measured using the Simpson
method, M-mode, and eyeball. Left
ventricular size was evaluated by measuring
left ventricular diameter in the apical 4-
chamber view. End-systolic and end-diastolic
volumes were measured both in the apical 4-
chamber view. The reference limits of all
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Echocardiography and Rheumatoid Arthritis Nikdoust F, et al.
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echocardiographic parameters were defined
according to the guidelines of the American
Society of Echocardiography.9
Statistical Analysis
The continuous variables are shown as means
SDs, and the categorical variables are
described as numbers (percentages). The
Student t-test was drawn upon to compare the
continuous variables between the study
groups, and the 2
test was used to compare
the categorical variables between the groups.
A P < 0.05 was considered statistically
significant. The statistical analyses were
performed using PASW, version 18 (SPSS
Inc., Chicago, Illinois, USA).
RESULTS
In the present study, we compared 48 patients
with RA of at least 5 years duration (mean
age = 51.3 11.9 y; male gender =11
[23.9%]) with 46 healthy individuals as the
control group. The mean duration of disease
in the patients with RA was 10.7 5.7 years.
Thirty-one (67.4%) patients of the case group
were under treatment with prednisolone, 27
(58.6%) with methotrexate, 5 (10.4%) with
hydroxychloroquine, and 4 (8.6%) were
treated with either CellCept or sulfasalazine.
Except for the body mass index (P = 0.012)
and systolic blood pressure (P = 0.011), both
groups were more likely to be similar in the
demographic and clinical variables. The
baseline characteristics of the study groups
are compared in Table 1.
In the echocardiography of the patients with
RA, 2 patients were revealed to have
rheumatoid nodules. (Both were female with a
disease duration > 10 y.) None of the cases
had pericarditis or any other specific finding
in the echocardiographic evaluation. The only
echocardiographic parameter that had a
significant indirect correlation with RA
duration was tricuspid annular plane systolic
excursion (TAPSE) (r = -0.29; P = 0.046). No
other echocardiographic characteristic was
correlated with the duration of RA.
Table 1. Comparison of the baseline general characteristics between the patients with RA and the healthy controls
Parameters Controls (n=48) Patients with RA
(n=46) P
Age, y 50.29.2 51.311.9 0.68
Male gender, n (%) 16 (33.3) 11 (23.9) 0.4
Diabetes mellitus, n (%) 5 (10.4) 7 (15.2) 0.141
Hypertension, n (%) 6 (12.5) 7 (15.2) 0.77
Dyslipidemia, n (%) 0 (0) 2 (4.3) 0.135
Smoking, n (%) 6 (12.5) 7 (15.2) 0.341
BMI, kg/m2 24.22.6 26.54.1 0.012
Abnormal ECG, n (%) 0 (0) 6 (13.0) 0.064
Systolic blood pressure 118.77.9 126.312.8 0.011
Diastolic blood pressure 80.53.5 80.24.0 0.795
Pulse rate, bpm 87.2+7.1 81.59.3 0.199
Respiratory rate /min 16.01.6 14.91.7 0.257
RA, Rheumatoid arthritis; BMI, Body mass index
In the comparison between the patients with
RA and the control group for the
echocardiographic parameters, the frequency
of mitral regurgitation (MR) was significantly
higher in the RA group than in the normal
controls (52.1% vs. 29.1%; P = 0.023).
Moreover, the degree of MR was significantly
higher in the RA group (P = 0.046). Similarly,
the number of patients with tricuspid
regurgitation was significantly higher in the
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Echocardiography and Rheumatoid Arthritis Nikdoust F, et al.
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RA group (P = 0.020), although the degree of
regurgitation did not differ statistically
between the 2 groups (P=0.353). The
frequency of patients with aortic insufficiency
was significantly higher in the RA group,
while there was a trend toward worse aortic
regurgitation severity in the RA group
(P=0.002 and P=0.071, respectively). The
other echocardiographic parameters were also
significantly disturbed in the RA group, as is
depicted in Table 2, particularly left
ventricular ejection fraction and heart
chamber dimensions. Nonetheless, pulmonary
artery pressure was statistically similar
between the groups.
Table 2. Comparison of the echocardiographic characteristics of the patients with RA and the healthy controls
Parameters Controls (n=48) Patients with RA
(n=46) P
MR, n (%) 14 (29.1) 24 (52.1) 0.023
MR severity, n (%)
0.046
Trivial 8 (16.7) 4 (8.7)
Mild 6 (12.5) 15 (32.6)
Mild to moderate 0 (0) 3 (6.5)
Moderate 0 (0) 2 (4.3)
TR, n (%) 14 (29.1) 28 (60.8) 0.02
TR severity, n (%)
0.353 Trivial 6 (12.5) 6 (13.0)
Mild 8 (16.7) 20 (43.5)
Moderate 0 (0) 2 (4.3)
AI, n (%) 8 (16.6) 21 (45.6) 0.002
AI severity, n (%)
0.071
Trivial 6 (12.5) 5 (10.9)
Mild 2 (4.2) 10 (21.7)
Mild to moderate 0 (0) 1 (2.2)
Moderate 0 (0) 5 (10.9)
LVEF, % 57.94.8 53.04.5
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association between the echocardiographic
parameters and the duration of the disease,
which is similar to the results of a single
study.20
Several mechanisms have been proposed for
diastolic dysfunction in patients with RA;
these mechanisms include myocardial
fibrosis, myocarditis, granulomatous lesions,
infarction, vasculitis, and focal
inflammation.21-24
Chronic immune activation
and inflammatory processes play a significant
role in the cardiac involvement of patients
with RA. Cytokine overactivityparticularly
TNF-contributes in the cardiomyocyte
apoptosis, ventricular dysfunction/
remodeling, and finally heart failure.25-27
Moreover, high inflammatory markers are
associated with significantly high plasma NT-
proBNP levels in patients with RA as
compared to controls.20
All these processes
can result in increased cardiovascular
mortality. This increased risk is so high that a
study showed that the prevalence and extent
of myocardial ischemia in asymptomatic
patients with RA was as much as that in
patients with type 2 diabetes mellitus.28
A
recent meta-analysis has shown an increase in
absolute and indexed left ventricular mass in
otherwise healthy patients with RA. This
increase was associated with an increased risk
of cardiovascular events and thereby
mortality.29
The disturbances in the
echocardiographic parameters in our study
also suggest the burden of RA on the
cardiovascular system of the patients. Overall,
cardiovascular assessment in patients with
RA, even in the absence of the related
symptoms, seems to be crucial.
It should also be noted that some of the drugs
used for the treatment of RA have cardiotoxic
effects. These adverse effects include heart
failure, myocarditis, and vasculitiswhich
are mostly caused by chloroquine,
hydroxychloroquine, and gold salts.30,31
Therefore, distinction between the exact
etiologies of cardiac abnormalities in patients
with RA seems difficult.
We also noticed that left ventricular end-
diastolic and systolic diameters were
significantly higher in the patients with RA,
which may be a sign of diastolic dysfunction.
This is in line with another study that showed
that left ventricular diastolic function was
impaired in patients with prolonged RA.31
Study Limitations
First and foremost among the limitations of
the current study is its limited number of
participants. RA is not a very common
disease and, thus, case selection for clinical
studies on RA is challenging. Moreover, this
was a single-center study in a university
hospital, where patients receive standard care
and treatment. It is, therefore, probable that
the patients in this study were well-controlled
and, consequently, had an acceptable clinical
condition with minimal complications as
opposed to patients with RA who live in
smaller cities and may, as such, not receive
ideal care and may develop more
complications such as cardiovascular
involvement. We would recommend a
multicenter study including a larger number
of patients with RA in different stages of the
disease. Long follow-up of patients and
regular echocardiographic evaluations may
help us understand the exact changes in the
cardiac function and structure in patients with
RA.
CONCLUSIONS
Transthoracic and Doppler echocardiography
is a useful method for assessing
cardiovascular involvement in RA. Our study
showed valvular involvement as well as
ventricular dysfunction in patients with RA
with significantly different echocardiographic
parameters as compared to those in the
healthy controls. The findings of the present
study highlight the necessity of the
assessment of the cardiac function in patients
with RA. Further research is needed on the
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various aspects of the cardiac involvement in
RA.
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al; 2
016
; 17 (2)
Incidence of CAD in Patients Presenting with Aortic Dissection Examined by 256-Slice CT-Angiography Azarnik H, et al.
25
Original Article Incidence of CAD in Patients Presenting with Aortic Dissection Examined by 256-Slice CT-Angiography Azarnik H, et al.
256-Slice Computed Tomography in the Diagnosis of Coronary
Artery Disease in Patients Presenting With Aortic Dissection
Between 2011 and 2014 and the Influence of Concomitant Coronary
Artery Disease on in-Hospital Mortality
Hossein Azarnik1, MD; Majid Kyavar
1, MD; Shabnam Madadi
1*, MD;
Nasim Naderi1, MD; Farzad Kamali
1, MD; Amir Khosropour
1, MD;
Javad Robat Sarpoushi1, MD; Armin Marashizadeh
1, MD
ABSTRACT
Background: In recent years, noninvasive methods have replaced angiography in the diagnosis of
aortic dissection and concomitant coronary artery disease (CAD). Computed tomography
(CT) angiography allows the assessment of CAD in this setting.
Methods: In this retrospective study, we investigated the incidence of CAD in patients presenting
with type A or B aortic dissection between 2011 and 2014 as assessed by CT angiography
and the influence of concomitant CAD and coronary artery bypass grafting (CABG) on the
in-hospital outcomes of these patients.
Results: Ninety-one patients (67% male) were included in this study. Thirty-five (38.5%) patients
had concomitant CAD on their CT angiography, and coronary artery ectasia was observed in
17 (18.7%) patients. Sixty-seven (73.6%) patients underwent surgery for their aortic
dissection. Concurrent CABG was performed in 22 (62.8%) patients, who had significant
coronary stenosis on coronary CT angiography. Mortality was significantly higher in the
patients who had concomitant CAD. (Sixty-seven percent of the patients with CAD died;
P
-
Ira
nia
n H
eart Jo
urn
al; 2
016
; 17 (2
)
Incidence of CAD in Patients Presenting with Aortic Dissection Examined by 256-Slice CT-Angiography Azarnik H, et al.
26
ortic dissection (AD) is a condition
with high mortality.3 Coronary artery
disease (CAD) risk factors may be
seen in patients with AD.1,3
Therefore,
patients with AD may have concomitant CAD
and their clinical outcome may exacerbate.2,4
The incidence of CAD in AD has been
reported to be between 25% and 35% in
different studies.5,7,8,9
For many years, there has been a debate as to
whether or not perform coronary angiography
in the setting of AD. Some studies have
shown the potential survival benefits of
preoperative coronary angiography in patients
with type A dissection. On the other hand,
some other studies have demonstrated no
remarkable benefits derived from coronary
angiography. In fact, the latter studies have
found coronary angiography to be associated
with higher mortality due to delay in
surgery.9,10,11
Computed tomography (CT) angiography
allows the assessment of CAD in this setting.
CT angiography is noninvasive and can be
done simultaneously with aortic evaluation.
In this study, we investigated the incidence of
CAD in patients presenting with type A or B
AD as assessed by CT angiography and the
influence of concomitant CAD and coronary
artery bypass grafting (CABG) on the in-
hospital outcome of these patients.
METHODS
In this retrospective study, the hospital
records of patients admitted with a diagnosis
of AD between 2011 and 2014 were
reviewed. The inclusion criterion was any
type of AD (A or B, acute or chronic) in
which the coronary artery anatomy was
defined by 256-slice coronary CT
angiography. The exclusion criteria
comprised any patient with postoperative
dissection (CABG and aortic valve
replacement) and coronary artery involvement
due to dissection flap propagation down the
coronary artery.
The demographic data, treatment plans, and
in-hospital mortality were recorded from
hospital documents. All CT angiographic
results were reviewed, and data regarding AD
and the coronary artery anatomy were
recorded. The diagnosis, treatment, an