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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

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OFFICIAL QUARTERLY PUBLICATION OF THE IRANIAN HEART ASSOCIATION

2

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

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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)

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E-mail: [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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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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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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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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2. Hennein HA, Mosca RS, Urcelay G et al.

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3. Abd El Rahman MY, Abdul-Khaliq H, Vogel

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echocardiographic assessment of pulmonary

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(2004) 147:165172

9. Snider AR, Serwer GA, Ritter SB.

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technique. J Comput Assist Tomogr (1984)

8:588593

11. Gutberlet M, Boeckel T, Hosten N et al.

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initial experience. Radiology (2000) 214:467475

12. Lotz J, Meier C, Leppert A et al.

Cardiovascular flow measurement with phase-

contrast MR imaging: basic facts and

implementation. Radiographics (2002)

22:651671

13. Cullen S, Celermajer DS, Franklin RC et al.

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arrhythmia after repair of tetralogy of Fallot :

a 12-year prospective study. J Am Coll

Cardiol (1994) 23:1151 1155

14. Gatzoulis MA, Balaji S, Webber SA et al.

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356:975981

15. Bogren HG, Klipstein RH, Mohiaddin RH et

al. Pulmonary artery distensibility and blood

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16. Majid Kyavar, Shabnam Madadi* and

Somayeh Esmaili. Pulmonary artery end-

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complication in patients with tetralogy of

Fallot total correction Journal of Cardiovascular Magnetic Resonance 2015,

17(Suppl 1)

17. Anita Sadeghpour, Majid Kyavar, Shabnam

Madadi, Leili Ebrahimi, Zahra Khajali, Zahra

Alizadeh Sani. Doppler derived strain and

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Madadi, Lili Ebrahimi, Zahra Khajali, Zahra

Alizadeh, Pedram Golnari. Comparison

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Atrioventricular Junctional Ablation in Atrial Fibrillation Kia M, et al.

12

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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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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Echocardiography and Rheumatoid Arthritis Nikdoust F, et al.

18

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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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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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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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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11. Mavrogeni S, Dimitroulas T, Gabriel S, Sfikakis PP, Pohost GM, Kitas GD. Why

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12. Liebowitz W. The heart in rheumatoid arthritis: a clinical and pathological study of

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13. Apstein CS, Eberli FR. Diastolic function and dysfunction with exercise, hypertrophy,

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14. Aurigemma GP, Gaasch WH. Diastolic heart failure. N Engl J Med. 2004;351(11):1097-

105.

15. Lester SJ, Tajik AJ, Nishimura RA, Oh JK, Khandheria BK, Seward JB. Unlocking the

mysteries of diastolic function: deciphering

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Cardiol. 2008;51(7):679-89. Epub 2008/02/19.

16. Nishimura RA, Tajik AJ. Evaluation of diastolic filling of left ventricle in health and

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17. Di Franco M, Paradiso M, Mammarella A, Paoletti V, Labbadia G, Coppotelli L, et al.

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19. Rexhepaj N, Bajraktari G, Berisha I, Beqiri A, Shatri F, Hima F, et al. Left and right

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Symptomatic cardiac involvement in juvenile

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30. Nicola PJ, MaraditKremers H, Roger VL, Jacobsen SJ, Crowson CS, Ballman KV, et al.

The risk of congestive heart failure in

rheumatoid arthritis: a populationbased study over 46 years. Arthritis Rheum.

2005;52(2):412-20.

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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

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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

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