Vol 3-4 Review Article

Stented Porcine and Pericardial Bioprostheses - A historical review

Andrea De Martino1, Giosuè Falcetta1, Aldo D. Milano2, Uberto Bortolotti1*

1Cardiovascular Surgery Divisions, University of Pisa, Italy

2Department of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy

Stented bioprostheses have been extensively used clinically to replace diseased cardiac valves with the clear advantage over mechanical prostheses of avoiding the use of chronic anticoagulation in most cases. During the past five decades, however, based on clinical and pathological experience, tissue calcification and cusp tears were identified as the main determinants of failure of porcine and pericardial bioprostheses, respectively. Tissue treatments to mitigate dystrophic calcification together with structural modifications in valve design have produced a current generation of bioprosthetic valves which show excellent overall performance and considerably increased durability when compared with old models. Further ongoing research aims to provide even more durable bioprostheses in order to allow reduction of the age threshold for implantation also in younger subjects, helping to contrast effectively the rapidly expanding role of catheter-based interventions.

DOI: 10.29245/2578-3025/2019/5.1179 View / Download Pdf
Vol 3-4 Original Research Article

Long Term Health Outcomes Following Coronary Artery Bypass Grafting: A Different Journey for Men and Women

G.M. Lindsay*, P.R. Ponaiah, I. Nomani, S.M. Lamadah, N.A. Tayyib and A. Johargy

College of Nursing, Umm Al-Qura University, Taif Road, Makkah, Saudi Arabia

Background: The applicability of the Short Form (SF36) questionnaire to disparate populations led us to use this tool to investigate how health-related quality-of-life (HRQoL) for patients who underwent coronary artery bypass grafting (CABG) is related to gender, age and survival.

Method: SF36 data and the presence of cardiac symptoms were collected from 44 women and 166 men prior to surgery and from consenting survivors at one and eight-year follow-ups. Survival data were collected from government records for 18 years post operation. Paired t-tests, Pearson correlation coefficients, chi-squared tests and the log-rank test were used to investigate connections between HRQoL and age, presence of angina/breathlessness and survival within and across genders.

Results: HRQoL improved significantly for males and females in almost all health domains at the one year follow-up. At the eight year follow-up most female domain scores showed further improvement whereas the majority of male domain scores declined. Cardiac symptoms were present in 75.8% of women and 68.3% of men (χ2=0.7120, p=0.3988) at the one-year follow-up, and 84.2% of women and 70.2% of men at the eight-year follow-up. Male long term survival (53.6% after 18 years) depended significantly on retaining post-operative improvements in HRQoL to the medium term (p<0.002 in 4 of 8 domains). Female long term survival (40.9%) was significantly less than male survival (p=0.0108) and depended on maintaining a steady upward trend in HRQoL over the medium term. Age was not a determinant in HRQoL following CABG. Long term male and female survival was not significantly different and approached those of age and gender matched samples from the general population.

Conclusion: Strategies to improve HRQoL in women may support improved survival by reducing excess short term female mortality, but the effectiveness of the same strategy for men is less apparent.

DOI: 10.29245/2578-3025/2019/4.1171 View / Download Pdf
Vol 3-4 Mini Review

Human Perivascular Adipose Tissue as a Regulator of the Vascular Microenvironment and Diseases of the Coronary Artery and Aorta

Caitlin Stieber, Kimberly Malka, Joshua M. Boucher, Lucy Liaw*

Center for Molecular Medicine, Maine Medical Center Research Institute, United States

Perivascular adipose tissue (PVAT) is an adipose depot that surrounds blood vessels in the human body and exerts local paracrine signaling. Under physiologically healthy conditions, PVAT has an anti-contractile effect on vessels, but in obesity this effect is lost. During metabolic disease, adiponectin secretion is dysregulated, influencing nitric oxide bioavailability and macrophage infiltration and inflammation, all of which mediate PVAT signaling. However, based on the location in the body, and the type of adipocyte present, PVAT has different relationships with risk factors for disease. Imaging studies in patients with cardiovascular disease have demonstrated important associations between PVAT structure and pathology, yet insight into molecular pathways regulating human PVAT function are still lacking. This review focuses on our current understanding of human PVAT and its secretory role in the vascular microenvironment. A current area of priority is defining molecular differences in the secretome between PVAT depots, as this could inform the treatment of diseases that occur in anatomically restricted locations. In addition, understanding progressive changes in PVAT structure and function during metabolic disease is required for effective targeted therapies.

DOI: 10.29245/2578-3025/2019/4.1174 View / Download Pdf
Vol 3-4 Original Research Article

Troponin Assay in the Real World: Is it Always a Diagnosis of Acute Myocardial Infarction?

Aidan (Jia Sheng) Yu1*, James Nguyen1, Anthony Brown2

1Royal Brisbane and Women’s Hospital Butterfield Street and Bowen Bridge Road, Herston, Queensland, 4029, Australia

2Gold Coast University Hospital, 1 Hospital Blvd, Southport QLD 4215

Background: The soon to be implemented state-wide introduction of high-sensitivity troponin assays will allow the use of a lower threshold in identifying patients with acute myocardial infarction (AMI). Whether this assay will be too sensitive and therefore produce increased false positive results is still unclear. We aim to investigate whether a significantly elevated cardiac troponin using the current troponin assay (cTnI) will result in a clinical diagnosis of AMI.

Methods: A retrospective study was performed at a Queensland Hospital with all cTnI ordered across a single month reviewed. Patients who were diagnosed with Non ST-Elevation Myocardial Infarction or ST-Elevation Myocardial Infarction were labelled as having an AMI.

Results: In total, 944 investigations were ordered for 628 patients. Using the hospital laboratory cutoff of >0.040 μg/L(>99th percentile) for significance, a positive result was obtained in 105 patients (16.7%) and a negative result in 523 patients (83.3%). The positive troponin results were attributed to AMI (20%), congestive heart failure (20%), sepsis (19%), tachyarrhythmias (16.2%), renal failure (8.6%), airway disease (8.6%), pulmonary embolism (3.8%) and others - pericarditis, post angioplasty etc (3.8%). cTnI was found to be highly sensitive (100%, 95%CI 84-100%) and specific (86%, 95%CI 83-89%) for AMI. However, only 21 (3.3%) of 628 patients investigated received a diagnosis of AMI. The positive predictive value was poor (20%, 95% CI 13-29%), with the negative predictive value absolute (100%, 95% CI 99-100%).

Conclusion: Current troponin assays were found to be highly sensitive and specific in diagnosing AMI. However, its poor positive predictive value may be contributed by inappropriate requests.

DOI: 10.29245/2578-3025/2019/4.1176 View / Download Pdf
Vol 3-4 Review Article

Long Non-Coding RNAs: Crucial Players of Cardiomyocyte Apoptosis

Xiatian Chen1,2, Ziqian Liu1,2, Zhe Li1,2, Jinning Gao1,2, Zhongjie Yu1,2, Peifeng Li1*, Lynn Htet Htet Aung1*

1Center for Molecular Genetics, Institute for Translational Medicine, Qingdao University, Qingdao, 266000, Shandong, China

2School of Basic Medicine, Qingdao University, Qingdao, 266000, Shandong, China

Long non-coding RNAs (lncRNAs) have gained more attention in recent years as a potential new regulator of nearly all biological regulation. LncRNAs are over 200 nucleotides in length, and it can interact with other non-coding RNAs or specific proteins to influence the gene expression. Cardiomyocyte apoptosis is associated with cardiovascular diseases. Accumulating studies have uncovered novel lncRNAs-mediated regulation of cardiovascular diseases; however, the knowledge of the mechanisms by how to act is still limited. This review highlights the role of lncRNAs involved in cardiomyocyte apoptosis with a focus on the regulatory axis. These examples may provide helpful insights on how lncRNAs interfere with cardiomyocyte apoptosis.

DOI: 10.29245/2578-3025/2019/5.1178 View / Download Pdf
Vol 3-4

Pleuropericardial Cyst: A Review of the Literature

Christina Koumantzia, Nikolaos Saridakis, Andreas Eleftheriou*

Department of Neurology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

Background: Pleuropericardial cysts (PPCs), account for 5 - 10% of all mediastinal tumours, are rare lesions occurring in approximately 1 in 100000 persons and are usually congenital and rarely acquired. They are detected post-mortem or incidentally on routine chest X-ray (CXR) and in most cases multi detector Computer Tomography is used to confirm the diagnosis. As benign course and clinical latency are characteristic features of such cysts and the occurrence of complications is rare, the majority of them can be left untreated.

Methods: The aim of the study is to review the literature regarding PPCs and create a table which summarises all the published cases in order to draw a conclusion about the epidemiology, as well as the diagnostic and therapeutic approach to PPCs exclusively. We reviewed retrospectively the clinical manifestation, diagnostic and therapeutic approach in 101 cases of PPCs since the 19th century.

Results: Our statistical analysis led to the following results: mean age of initial detection: 48.7 ± 17.2 years, female:male ratio: about 3:2, presence of symptomatology: 37/101 cases, most common location: right cardiophrenic angle (RCPA), most common method of initial detection: CXR in 49/101 cases, mean maximal diameter: 8,3 ± 3 cm.

Conclusion: The management of a pleuropericardial cyst should be based on an algorithm in which the cyst's size, shape and compressibility along with clinical presentation and patient's fitness and preferences are be taken into consideration. When interventional is required, surgical resection by means of traditional open surgery or minimally invasive methods are considered to be the gold standard and along with percutaneous aspiration are the methods that have mostly been used.

DOI: 10.29245/2578-3025/2019/4.1175 View / Download Pdf
Vol 3-4 Original Research Article

Healthcare Resource Utilization among Non-Valvular Atrial Fibrillation Patients Who Switched from Warfarin to a Novel Oral Anti-Coagulant

Jessica Franchino-Elder1, Adrienne Gilligan2, Xue Song2*, Briain O Hartaigh1, Caroline Henriques2, Amy Sainski-Nguyen2, Cheng Wang1

1Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA

2IBM Watson Health, Cambridge, MA, USA

Among patients with non-valvular atrial fibrillation (NVAF), switching from warfarin to novel oral anticoagulants (NOACs) is common, yet clarifying the differences in the effect of NOACs on all-cause healthcare resource utilization (HCRU) are unknown. Adult NVAF patients who switched from warfarin to dabigatran, apixaban, or rivaroxaban were identified in MarketScan databases between 10/2010-12/2015. Patients had 12 months pre-period (index date was 1st NOAC claim) and were followed up to 12 months until medication discontinuation, end of enrollment, inpatient death, or 12/2016. Overall, 8,679 and 5,761 dabigatran switchers were matched (1:1) to rivaroxaban and apixaban switchers (mean age 73-74 years). Compared with rivaroxaban switchers, a lower proportion of dabigatran switchers had an inpatient (IP) visit (20.0% vs. 21.6%, p=0.008). Dabigatran switchers had lower per-patient-per-month (PPPM) total outpatient (3.87 vs. 4.06, p=0.002), emergency department (ED; 0.48 vs. 0.52, p=0.026), outpatient office (1.17 vs. 1.22, p<0.001), and other outpatient (2.71 vs. 2.83, p=0.043) visits compared with rivaroxaban switchers. A similar proportion of dabigatran and apixaban switchers had an IP visit (20.7% vs. 21.2%); compared with apixaban switchers, dabigatran switchers had significantly more PPPM IP visits (0.23 vs. 0.21, p=0.031) but significantly lower ED visits (0.47 vs. 0.52, p=0.016). Post-discharge 30-day readmission rates were comparable among warfarin-to-NOAC switching groups. Time to readmission was longer for dabigatran versus rivaroxaban switchers (8.2 vs. 7.8 days, p<0.001), but comparable with apixaban patients (8.1 vs. 8.4 days). Switching to dabigatran after warfarin discontinuation may lower HCRU among NVAF patients compared with switching to rivaroxaban or apixaban.

DOI: 10.29245/2578-3025/2019/4.1177 View / Download Pdf
Vol 3-4 Original Research Article

Changes in Cardiac Isomyosin Composition in an Iron Loading Anemia Rat Model

Wei Ting Cheng, Na Yoon Kim, Prashant Bhattarai, Murui Han, Archita Venugopal Menon, Jonghan Kim, Ban An Khaw*

Department of Pharmaceutical Sciences, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, MA. USA

A rat model of iron loading anemia resulting in hypertrophic cardiomyopathy was used to assess the composition of cardiac isomyosin by ELISAs and immunohistochemistry relative to the chronological age of these animals and their normal controls. Cardiac myosin extracts of homozygous Belgrade (b/b) rats that develop hypertrophic cardiomyopathy were compared to those from the heterozygous (b/+) control rats at 4.5 and 11.5 weeks of age. Confirmation of the ELISA data in the increase in β-isomyosin in 11.5 weeks old b/b rat hearts were obtained by immunohistochemical staining relative to 4.5 weeks old b/b hearts and control 4.5 and 11.5 weeks old b/+ hearts. Quantitation and immunohistochemical demonstration of an increase in the β-isomyosin isoform can be confirmed in hypertrophic cardiomyopathy in iron loading anemia model.

DOI: 10.29245/2578-3025/2019/4.1172 View / Download Pdf
Vol 4-1 Case Report

Severe Symptomatic Bradycardia After Intravenous Immunoglobulin Infusion: A Rare Manifestation

Steven Douedi1*, Abbas Alshami1, Gina Francisco Ashforth1, Obiora Maludum2, Michael P. Carson1

1Department of Medicine, Jersey Shore University Medical Center, New Jersey, United States

2Department of Cardiology, Jersey Shore University Medical Center, New Jersey, United States

Intravenous immunoglobulins (IVIGs) are immunomodulating agents prepared using pooled plasma from thousands of human donors. These IVIGs have been used to treat a wide range of autoimmune, infectious, and idiopathic diseases. Their use in idiopathic thrombocytopenic purpura (ITP) was first described in 1981 and was found to be an effective alternative to splenectomy. The standard dose of IVIG in patients with ITP is 400 milligrams per kilogram body weight (mg/kg) daily for 5 days however recent data has shown a dose of 1 gram/kilogram/day for 2 days may be more effective. Side-effects during IVIG infusions have been reported in about 5 to 15% of patients. Cardiac related side-effects such as arrythmias, hypotension, and even myocardial infarction, being rare, have also been documented but are usually seen in patients with underlying cardiac pathologies. This article presents a 61-year-old male with no history of cardiac disease or arrhythmias who developed symptomatic bradycardia thirty minutes after intravenous immunoglobin infusion requiring multiple atropine injections and dopamine infusion over a 7-day hospitalization. The bradycardia resolved afterwards, and cardiac workup did not identify any underlying pathology.

DOI: 10.29245/2578-3025/2020/1.1185 View / Download Pdf
Vol 4-1 Case Report

Successful Transcatheter Aortic Valve Replacement After Iatrogenic Aortic Cusp Dissection After Treatment of Complex, Unprotected Left Main Bifurcation Coronary Artery Disease

Injoon Lee1*, Matthew P. Cauchi2, Jason Foerst1-3, Gary Swank1,2

1Section of Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

2Interventional Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

3Structural Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

Currently no literature exists regarding the safety and feasibility of transcatheter aortic valve replacement (TAVR) after aortic cusp dissection. Aortic dissection is a rare, albeit potentially fatal complication related to percutaneous coronary intervention, especially when dealing with heavily calcified coronary disease involving the left main. Rapid stratification of patients in need of early invasive repair versus conservative observation is crucial to patient morbidity and mortality. We present a case of an elderly female with severe aortic stenosis who underwent TAVR after complex intervention of heavily calcified multi-vessel coronary artery disease involving the left main and bifurcation with high-risk Impella protected rotational atherectomy and culotte stenting complicated by left coronary cusp dissection and was managed conservatively without long-term sequelae. This case highlights the achievability of TAVR after aortic cusp dissection that was treated with conservative methods.

DOI: 10.29245/2578-3025/2020/1.1183 View / Download Pdf
Vol 4-1 Case Report

Arterial Pandemonium: A Case Report of Pan-Aortic Dissection Masquerading as an Inferior Myocardial Infarction, Stroke and Bilateral Lower Extremity Paraplegia

Injoon Lee1*, Matthew P. Cauchi1, Amitabh Parashar2

1Virginia Tech-Carilion Clinic School of Medicine, Department of General Cardiovascular Disease, Roanoke, VA, USA

2Salem Veterans Affairs Medical Center, Department of Cardiology, Salem VA, USA

Background: Identifying and treating ST-elevation myocardial infarction (STEMI) in a timely manner is crucial in reducing the patient’s morbidity and mortality. However, sometimes STEMI can be caused by other pathologies such as aortic/coronary dissection, thromboembolism, septic emboli, or trauma. We present a case of a pan-aortic dissection (AD) with multi-system organ failure and shock presenting as anterior spinal cord syndrome, inferior myocardial infarction and stroke.

Case Presentation: A 62-year old woman with history of tobacco abuse and depression, presented to the Emergency Department (ED) for altered mental status. The patient was initially found outside of her home, unresponsive and bradycardic, with subsequent 12-lead electrocardiogram (EKG) demonstrating an inferior STEMI with right ventricle (RV) involvement and presumed cardiogenic shock. In the ED, the patient was awake with intermittent, though profound aphasia, as well as near complete loss of motor and sensory function in her lower extremities. She remained hypotensive and had weak peripheral pulses bilaterally in the upper and lower extremities. Emergent brain imaging was negative for ischemia, but chest imaging revealed circumferential mural thrombus extending from the aortic root into the descending aorta consistent with pan-AD and was taken urgently to the operating suite. Unfortunately, the patient died before surgical intervention could be performed.

Conclusion: This case report highlights a rare case of STEMI, stroke, cardiogenic shock and ultimately death caused by pan-AD. Timely identifying the underlying pathology in patients who present with more than typical STEMI symptoms is essential in providing potential lifesaving therapy.

• Aortic dissection symptoms can present with cardiovascular & neurological symptoms, end-organ compromise along with chest and/or abdominal pain.

• Clinicians should have high degrees of suspicion when myriad of symptoms are present in hemodynamically unstable patients.

• Aortic dissection can have numerous complications including death if not properly diagnosed and treated accordingly.

• Treatments of aortic dissection differs based on its type, hemodynamic status of the patient and any signs of end organ dysfunction.

DOI: 10.29245/2578-3025/2020/1.1184 View / Download Pdf
Vol 4-1 Mini Review Article

Metabolic Modulation to Treat Cardiac Diseases: Role for Membrane Substrate Transporters

Jan F.C. Glatz*, Joost J.F.P. Luiken, Miranda Nabben

Department of Genetics & Cell Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands

There is growing recognition of the importance and multiple roles of substrate energy metabolism in both cardiac health and disease. Cardiac diseases are frequently accompanied by altered myocardial metabolism, while chronic changes in the type of myocardial substrate utilization are found to elicit cardiac contractile dysfunction. Examples are the increased glucose utilization, at the expense of fatty acids, in cardiac hypertrophy and ischemic heart failure, and the increased fatty acid utilization, at the expense of glucose, in obesity and diabetes-related cardiac dysfunction. Modulation of cardiac metabolism has emerged as a suitable therapeutic intervention in cardiac disease. Insights obtained during the past decade have revealed sarcolemmal substrate transport, facilitated by CD36 for fatty acids and by GLUT4 for glucose, to represent the main rate-governing kinetic step of substrate utilization, over-ruling intracellular sites of flux regulation. This suggests that manipulating the presence of substrate transporters in the sarcolemma may be an effective approach for metabolic modulation therapy. The present mini-review provides a short summary of the functioning of substrate transporters CD36 and GLUT4 in the heart, and discusses their application as targets for metabolic intervention.

CD36: Cluster of Differentiation 36

FABPc: Cytoplasmic Fatty Acid-Binding Protein

FABPpm: Plasma Membrane Fatty Acid-Binding Protein

FATP: Fatty Acid Transport Protein

GLUT4: Glucose Transporter-4

SR-B2: Scavenger Receptor B2

VAMP: Vesicle-Associated Membrane Protein

v-ATPase: vacuolar-type H+-ATPase

DOI: 10.29245/2578-3025/2020/1.1187 View / Download Pdf
Vol 4-1 Mini Review Article

Influence of Chronic Cardiovascular Diseases on the Severity of Imported Falciparum Malaria

Bodo Hoffmeister1*, Abner Daniel Aguilar Valdez2

1Department of Respiratory Medicine, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

2Department of Endocrinology, Clinic Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

Falciparum malaria has a unique and complex pathophysiology. While sequestration of parasitized and non-parasitized erythrocytes leads to a progressive obstruction of the microcirculation, a marked systemic inflammation with endothelial dysfunction and consecutive increase in vascular permeability develops. Furthermore, most patients with severe disease present with some degree of hypovolemia. Due to the reduction in pre-load, direct myocardial suppression and increase in after-load acute falciparum malaria exerts diverse effects on the cardiovascular system. Increasing numbers of aging tourists and immigrants with chronic co-morbidities travel to countries where falciparum malaria is endemic. Age has consistently been described as a prominent risk factor for both severe disease and death from imported falciparum malaria in several large studies. Although for long suspected age-related chronic disorders have only recently been identified as risk factors for severe disease. Herein, we review the current concepts of the impact of age-related chronic medical conditions on the severity of imported falciparum malaria.

DOI: 10.29245/2578-3025/2020/1.1188 View / Download Pdf
Vol 4-1 Mini Review Article

Digital Health: New Approaches in Hypertension Management

Jamie Kitt1, Rachael Fox2, Katherine L Tucker3*

1Radcliffe Department of Medicine (Cardiovascular Division), University of Oxford, UK

2University of Melbourne, Melbourne, Australia

3Nuffield Department of Primary Care, University of Oxford, UK

Hypertension is a key risk factor for cardiovascular disease. Globally, approximately a third of people with hypertension remain undiagnosed, and of those diagnosed, about half are not taking antihypertensive medication. The World Health Organization has estimated that globally hypertension directly or indirectly causes the deaths of at least nine million people every year.

There is a trend towards self-monitoring of blood pressure (BP), where patients are empowered to be involved in hypertension screening and diagnosis. Novel technology, including smartphones and Blue-tooth® enabled telemonitoring, are new tools that are likely to be increasingly important in hypertension management. Several studies have shown the benefit of self-monitoring of BP coupled with co-interventions (such as telemonitoring) in improving BP management. However, these new technologies must be properly assessed and clinically validated prior to widespread implementation in the general population, or within special groups. In this mini-review, we examine how technology might improve the detection and management of hypertension.

DOI: 10.29245/2578-3025/2020/1.1186 View / Download Pdf
Vol 4-1 Mini Review Article

Vaccination Against Atherosclerosis: A Brief Review and Update

Hamideh Amirfakhryan*

Faculty of Health Science, University of South Wales, UK

Vaccination against atherosclerosis as a potential effective approach has been under investigation for more than 20 years. Different antigens have been tested in animals with a great success. Lipid-related antigens like Ox-LDL, PCSK9, non-lipid related antigens like interleukins, HSPs β2GPI, DNA vaccination and whole cell vaccination are some examples of successful examinations in animals. Plant-based vaccination which has some advantages over traditional methods has been attracted the scientists´ attention recently. Despite the very substantial struggles and promising results during these years, vaccination against atherosclerosis could not be utilized for the treatment of atherosclerosis in human in part due to the lack of clinical trials to access its safety and efficacy. In fact, designing clinical trials with a sufficient number of participants together with a sufficient duration of follow up to explore the influence of vaccine on the prevention and treatment of atherosclerosis seems to be an imperative requisiteness. It looks investing on clinical trials must be a priority to achieve a clear sight regarding the new, tempting, and promising strategy for vaccination against atherosclerosis.

DOI: 10.29245/2578-3025/2020/1.1190 View / Download Pdf