心血管疾患と診断

Background: The diagnosis precision of Brugada algorithm in discriminating between supraventricular tachycardia and ventricular tachycardia remains controversial. We aim to evaluate the diagnostic value of Brugada algorithm in broad complex tachycardia arrhythmia.
Methods: Eligible studies were identified through searching PubMed, Embase, Web of Science databases, Wan Fang data resource, China National Knowledge Infrastructure prior to 5st January 2018. Studies were assessed for quality using the Quality Assessment for Studies of Diagnostic Accuracy, 2nd version (QUADAS-2). Pooled sensitivity and pooled specificity with 95% confidence interval (CI) were calculated using random-effects models. Summary receiver operator characteristic (SROC) curves and the area under curve (AUC) were performed.
Results: A total of 13 studies including 1918 electrocardiogram (ECG) were enrolled in this meta-analysis. The pooled sensitivity and specificity were 0.92(95% CI: 0.88–0.95), and 0.71(95% CI: 0.57-0.82), respectively. The positive likelihood ratio was 3 (95% CI, 2.0–5.0) and the negative likelihood ratio was 0.11 (95% CI, 0.06–0.19). The summary Diagnostic Odds Ratio (DOR) was 29 (95% CI: 12–72). The AUC was 0.95. Meta-regression analysis showed that sample size, study type and region were not the major sources of heterogeneity, the publication date may account for heterogeneity.
Conclusion: Brugada algorithm has excellent pooled sensitivity and moderate pooled specificity for discriminating SVT from VT. It deserves to be widely used as clinical diagnostic methods.

Introduction: The aim of this study was to develop bidirectional block of intra-atrial reentrant tachycardias (IARTs) late after the repair of congenital heart disease (CHD) using pace-map and entrainment mapping.
Methods and results: There were 106 patients enrolled in this study. These patients were divided into two groups as giant right atrium (RA) group and non-giant RA group based on their RA volume measured by Carto. All patients have performed activation and entrainment mapping among these patients, 24 (22.6%) of Giant RA group had dual-loop reentry and 82 patients had single loop reentry. 94 patients (88.7%) found out the gaps by pace-map in SR. Linear ablation was successful in 105 patients (99%). During a mean follow-up period of 105 ± 34 months the success rate of IARTs was 66%, there were significantly different in these two groups(P<0.01). Seven (6.6%) patients in Giant RA group undergone redo procedure.
Conclusion: Entrainment mapping in tachycardia and pace-map combined with three-dimensional electroanatomic mapping can elaborate the mechanism of complex re-entry circuits and critical isthmuses as targets for ablation. Pace-map in SR may be a good method for seeking the gap of ablation line to be bidirectional block for linear ablation IARTs.

Objectives: Foods with high glycemic index (GI) and/or glycemic load (GL) have been reported to have etiology in the incidence and prevalence of diabetes mellitus (DM) and its related chronic metabolic diseases like cardiovascular diseases (CVDs) etc. facing the globe today. High GI in particular has been found to have positive association with hyperglycemia, DM and CVDs such as hyperlipidemia, hypercholesterolemia, atherosclerosis etc. Therefore, the aim of this study is to investigate soy flour fortified whole wheat meal consumed with Crassocephalum biafrae (Worowo) vegetable soup’s dietary glycemic index and glycemic load, and its effects on lipid profiles of the test human subjects.
Methods: Eighteen human subjects were divided into two equal groups (control and test groups) of nine participants each. After 12 h of overnight fasting, the control group were fed D-glucose (DG) on the first day of the experiment, while the test group were fed whole wheat meal cum Crassocephalum biafrae soup (WWMCBS) and soy flour fortified whole wheat meal cum Crassocephalum biafrae soup (SFFWWMCBS) on the first and second day respectively. Fasting blood sugar and random blood sugar levels were determined at 30 min interval for 2 h using glucometer and blood samples were collected 5 h after meal for lipid profiles assay.
Results: Findings showed that; SFFWWMCBS had GI and GL of 28.00% and 14.00 respectively that are nonsignificantly lesser than that of WWMCBS (42.67% and 21.34) respectively, and its consumption resulted in nonsignificant reductions in total cholesterol (140.00 mg/dl-139.33 mg/dl), triglyceride (84.00 mg/dl-78.33 mg/dl), low density lipoprotein cholesterol (60.67 mg/dl-57.67 mg/dl), but slight increase in high density lipoprotein cholesterol (62.33 mg/dl-65.00 mg/dl) in test human subjects at (p<0.05).
Conclusion: Conclusively, SFFWWMCBS had lower GI and GL than WWMCBS, and have the potentials to reduce CVDs risk factors, since it decreased cholesterol, triglyceride and LDL-C, but improved HDL-C.

Objectives: Our aim was to evaluate and compare the safety and reliability of the early coronary bypass operation either with off-pump or on-pump technique after carotid artery stenting (CAS) in ischemic patients.

Patients and methods: The data of 312 patients with combined coronary and carotid artery disease treated with CAS between 2010 and 2017 prior to CABG in two different centers: Saudi German Hospital in Saudi Arabia and central clinic Bad Berka in Germany were retrospectively reviewed. 189 patients were operated off-pump; they were referred to as group A. The remaining 123 patients were operated on-pump (group B). All patients were submitted for CAS hours before the CABG. In both groups the double antiplatelet therapy was given before and after the carotid stenting and continued after the CABG. Patients in both groups were investigated pre-and postoperative by CT brain and CT angiography of carotid artery. Patients were followed up for stroke, bleeding, MI and mortality for 2 years.

Results: Patients of group A had less mortality, less post-operative bleeding, less myocardial infraction and less stroke after CABG than those in group B. The early timing for the CAS prior to CABG was more safe and reliable in group A.

Conclusion: Early Off-pump CABG after CAS is safer for patients; with fewer complications and less mortality than in On-pump CABG.

Aim: To study the world literature on patients undergoing surgical repair of acute Stanford type A aortic dissection (ATAAD). We assessed if the volume or experience of the center or surgeon affects outcomes.

Methods: Literature was reviewed using the OVID platform for Medline® and Pubmed from 1966-2017. 51 papers were identified of which 12 studies met the inclusion criteria and represented the highest level of evidence to answer the research question.

Results: Retrospective cohort analysis of 1550 UK patients operated on by 249 surgeons using national audit data found low volume surgeons (LVS) had higher in-hospital mortality vs high volume surgeons (HVS) (19.3% vs 12.6%, P=0.015, OR: 0.853 CI: 0.733-0.992, P=0.039), but no relationship between mortality and center volume. Five large retrospective studies using the United States (US) Nationwide Inpatient Sample (NIS) database looked at 29292 cases. Higher-volume centers (HVC) were associated with lower mortality following ATAAD repair vs lower-volume centers (LVC) (27.5% vs 16.4%, P<0.001; 34% vs 25%, P=0.003; 23.4% vs 12.1%, P=0.014; 12.6% vs 23.9%, P=0.013). A single-center cohort study in Germany, UK and three in the US reported decreased mortality after introduction of a specialized team/protocol for ATAAD repair (34.5% vs 8%, P<0.001; 33.9% vs 2.8%, P<0.0001; 33.9% vs 7.7%, P<0.0001; 22.9% vs 9.7%, P=0.002; 30.8% vs 9.7%, P=0.014).

Conclusion: There is moderate evidence of a volume-outcome relationship for ATAAD surgery. This may be driven by surgeon or institutional volume. There is stronger evidence that establishing specialized multidisciplinary teams and standardized protocols reduces morbidity and mortality.

Objectives: There is no consensus about the optimal length of hospital stay in patients undergoing elective transfemoral TAVR under general anesthesia. Our study tried to find predictors of failure of early discharge strategy in those patients.

Methods and results: We included retrospectively 135 high risk TAVI patients (mean Log. EuroSCORE 30.8 ± 6) operated under general anaesthesia between June 2017 and January 2018 in central hospital, Bad Berka, Germany. Focus on the preoperative factors was established in favor to find possible predictors of longer hospital stay in this group of patients. Uni- and multivariate analysis were performed to identify independent preoperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the hospital five days after surgery. Independent predictors of fast-track protocol failure were NYHA IV (OR 4.3; CI 95% 2.3-25, p-Value 0.017), ejection fraction (EF) ≤ 30% (OR 3.5; CI 95% 2-12.5, p-Value 0.006), right bundle branch block (OR 4.7; CI 95% 1.25-25, p-Value 0.03) and stroke with residual disability (OR 4.5; CI 95% 1.1-16, p-Value 0.025).

Conclusion: NYHA IV, severely reduced ejection fraction, right bundle branch block and stroke with residual disability might be considered potential predictors of failure of fast track protocol in patient undergoing TAVI under general anesthesia.

Background: Coronary atherosclerosis is one of the most significant diseases in recent years. CCTA can provide a non-invasive quantitative assessment of coronary atherosclerotic plaque.

Objectives: To describe a novel score with CCTA in assessment of coronary atherosclerotic plaque characteristics in patients with acute coronary syndrome (ACS).

Methods: We retrospectively analyzed 213 patients from Jun 2012 to Jun 2014. All patients were classified into four groups: healthy individuals as a control group, unstable angina group (UA), non-ST-segment elevation myocardial infarction group (NSTEMI) and ST-segment elevation myocardial infarction group (STEMI). Segment involvement score (SIS), segment stenosis score (SSS) and a novel CCTA score (CCTAs) were calculated, respectively. All evaluation indicators were analyzed with SPSS 20.0 software. All images were analyzed by two experienced radiologists, they had no knowledge of clinical or angiographic results.

Results: 1. Significant differences were found among all groups of age (P=0.007), SBP (P=0.013), and males (P=0.047). 2. Significant differences in SIS, SSS, CCTAs were found between the UA, NSTEMI and STEMI groups (P=0.00) 3. SBP and CCTAs were found to be independent risk factors of UA (OR=1.042, P=0.008; OR=1.211, P=0.000, respectively). CCTAs were independent risk factors of MI (OR=1.77, P=0.000). 4. With healthy group as control, for group UA, AUC of CCTAs was 0.741. For group MI, AUC of CCTAs was 0.955. The efficiency of simultaneously identifying cases (i.e., SBP and CCTAs) in group UA was 0.850.

Conclusion: CCTAs are more robust than SIS, SSS scores for the diagnoses of patients with ACS.

Background: Paravalvular leak (PVL) can complicate mitral and aortic valves replacement. Most PVLs are often clinically insignificant. However, large leaks can lead to heart failure and infective endocarditis. Intravascular hemolytic anemia is common in small PVLs. Reoperation for closure of PVL is associated with high mortality. Transcatheter closure is less invasive and can be used in high-risk patients.

Case summary: We present a case of a 38-year-old man with a history of Aortic Valve replacement (AVR) and Mitral valve replacement (MVR) who developed hemolytic anemia and haemoglobinurea. The patient was managed initially conservatively but later underwent redo valve surgery after exclusion of other causes of hemolytic anemia. Postoperatively, haemoglobinurea disappeared dramatically whereas anemia resolved gradually after surgery.

Discussion: Significant intravascular hemolysis is a rare but serious complication of PVL that poses diagnostic problem to cardiac surgeons, but also for cardiologists and internal medicine professionals especially when the prosthetic valve function is considered adequate. PVL is the flow of blood through a track between the native cardiac tissue and the implanted valve due to any compromise in closure between the two. PVL is also more frequently seen after mitral (up to 20%) valve replacement than aortic prosthetic valves. PVLs are more frequently diagnosed by Transesophageal echocardiography (TEE) than Transthoracic echocardiography (TTE) due to its ability to detect minute jets of regurgitated blood.

Conclusion: Either repair or re-replacement of prosthetic valves with PVLs is needed in about 1% to 5% of patients. The case study is presented to highlight PVL as a rare cause of haemoglobinurea and hemolytic anemia.

Introduction: Cardiovascular morbidity and mortality has been a tremendous cause of burden on the healthcare economy and is a major event in the Bahraini population. The same applies to vitamin D deficiency, which is a widely prevalent health problem, and in Bahrain more specifically. A limited amount of data has been published looking at the prevalence of vitamin D deficiency in patients with myocardial infarction, but only one study was done in the middle-eastern region.
Method: 50 patients with myocardial infarction (both ST elevation and non-ST elevation) were included in a 2- month duration between May and July 2017. Inclusion criteria for the study were, age ≥ 30 years, biomarker evidence of myocardial injury (elevated troponins or CKMB), other supporting evidence of MI (ECG charges, chest pain, hemodynamic instability). Low levels of vitamin D were considered as <20 ng/ml.
Results: Of the 50 enrolled patents (including both ST elevation and non-ST elevation MI), 43 (86%) were found to have low vitamin D levels.
Conclusion: Vitamin D deficiency is present in most of the patients with acute myocardial infarction.