Diagnostic accuracy of computed tomography coronary angiography in patients presenting with heart failure of unknown etiology in the middle east Ahmed Fathala, Dhaifallah Shwaihi, Mohamamed M Shoukri, Mashael K Alrujaib Heart Views 2019 20(3):77-82 Objectives: The purpose of this study is to assess the diagnostic performance of coronary artery calcium score (CACS), computed tomography coronary angiography (CTCA), and the prevalence of coronary artery disease (CAD) as etiology of heart failure (HF) in the Middle Eastern population. Background: CTCA has several advantages compared to invasive coronary angiography (ICA). However, studies on the diagnostic accuracy of CTCA and CACS in detecting the prevalence of CAD in patients with newly diagnosed HF are lacking in the Middle East. Methods: This study included 204 patients with symptoms of HF and ejection fraction (EF) of <50% by echocardiography who underwent CTCA for diagnosis of CAD within 3 months. The exclusion criteria were defined as patients with a history of CAD, percutaneous coronary intervention, or coronary artery bypass grafting. All patients with obstructive CAD based on CTCA were referred for ICA. In addition, 30 patients with normal CTCA also underwent ICA for verification. Results: The mean age was 48 ± 13 years, 69% (n = 141) were male and 31% (n = 73) were female, mean left ventricular EF was 31% ± 9%, and mean CACS was 58 ± 120. Based on the CTCA results, 169 patients had normal or nonobstructive CAD, whereas 35 patients had obstructive CAD. ICA was performed in all 35 patients with obstructive CAD; 30 of them were confirmed as having abnormal ICA, and only 5 had nonobstructive CAD. In addition, 30 patients with normal CTCA underwent ICA testing and were confirmed as having normal ICA. The CTCA had 100% sensitivity, 84% specificity, 86% positive predictive value, and 100% negative predictive value. Of the total population, 30 (15%) who were documented as having obstructive CAD were classified as CAD HF based on ICA. The remaining 174 (85%) patients were classified as having no CAD HF based on normal CTCA and/or ICA. The prevalence of CAD HF based on ICA was 15%. There was a strong correlation between CACS and both CTCA and ICA, with P = 0.001 and 0.0048, respectively. Conclusion: In patients with newly diagnosed HF, CACS and CTCA had a 100% sensitivity and negative value as well as overall excellent diagnostic accuracy. CACS = 0 excluded CAD as the etiology of HF with correlation between CACS groups and both CTCA and ICA. The prevalence of CAD as etiology of HF in the study population was 15%.

The effect of contrast administration on renal function after cardiac catheterization in Saudi patients Mohammed Ali Balghith Heart Views 2019 20(3):83-86 Background: The increase of serum creatinine by 25% from the baseline readings will lead to contrast-induced nephropathy. Most of the time this acute reduction in kidney function will occur in the first 48 h after angiogram; diabetes mellitus (DM) is one of the major predisposing factors. Objectives: Our objective is to study the influence of contrast material administration during angiogram on kidney function, especially in patients with risk factors such as DM in the Saudi community. Methods: This was an open-label study; we included 1250 patients from July 2010 to June 2011, and we studied all comers during that period; more than 60% of admissions came through the emergency department with acute coronary syndrome, in addition to elective admission with stable computer-aided design. Results: The incidence of nephropathy related to the contrast used during angiogram was 4.8%, and this represents 60 patients of 1250. Of the 60 patients, the number of diabetic patients who developed nephropathy was 37 (62%). 40 (67%) patients were hypertensive. Twenty-five (42%) patients had body weight <70 kg, 37 (62%) had diagnostic cath, 23 (38%) underwent percutaneous coronary intervention, and 47 (78%) received Omnipaque contrast media. Conclusion: The incidence of nephropathy postcoronary angiogram was 4.8%; the two major risk factors in our Saudi patients were hypertension and diabetes; the diabetic patients should be monitored precisely, and special measures should be taken seriously.

Percutaneous antegrade and retrograde endovascular approach to symptomatic high-grade subclavian artery stenosis: Technique and follow-up Santhosh Krishnappa, Jayasheelan Mambally Rachaiah, Srinidhi S Hegde, Kanchanahalli Siddegowda Sadananda, Manjunath Cholenahally Nanjappa, Govardhan Ramasanjeevaiah Heart Views 2019 20(3):87-92 Background and Purpose: Angioplasty and stenting of the subclavian artery have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates. Different antegrade or retrograde endovascular catheter-based approaches are used. Nowadays, endovascular therapy has taken over open surgical techniques in subclavian artery disease. The purpose of this study was to determine safety, efficacy, and midterm clinical and radiological outcome of the endovascular treatment with special focus on the different technical approaches in subclavian artery disease. Materials and Methods: Between 2014 and 2017, 11 patients (10 men, 1 woman) with symptomatic high-grade stenosis (90%–100%) of the subclavian artery were treated with endovascular treatment. Their mean age was 51.3 years (range, 32–61 years). Mean angiographic and clinical follow-up was 22.5 months (range, 5–44 months). Clinical follow-up was performed at hospital discharge and routine follow-up was performed at 1, 3, 12 months, and 6 monthly thereafter. In all 11 patients, a percutaneous approach was used successfully. In eight patients, the lesions were accessed retrogradely through a brachial artery puncture. Results: Acute success rate was 100%. There were no significant peri-procedure complications. At the latest clinical follow-up (mean of 22.5 months), all patients showed a good outcome with a restenosis rate of 18.2% including a patient with Takayasu arteritis. Conclusion: Percutaneous antegrade and retrograde stenting of high-grade subclavian artery stenosis is a viable less invasive alternative to open bypass surgery with good midterm clinical results and patency rates.

Single center 7 year experience of coronary artery perforation: Angiographic and procedural characteristics, management and outcome Jaywant M Nawale, Ajay S Chaurasia, Nikhil Anand Borikar, Digvijay Deelip Nalawade, Meghav M Shah, Prashant S Shinde Heart Views 2019 20(3):93-100 Context: Coronary artery perforation is a rare but potentially catastrophic complication of percutaneous coronary intervention (PCI). It is infrequent complication of PCI. Aims: The objective of the study is to report the 7-year experience of coronary artery perforation with respect to incidence, clinical and angiographic characteristics, management and outcomes. Settings and Design: The study involved retrospective analysis of single centre 7 years of percutaneous coronary intervention data. Patients who had complication of coronary artery perforation during PCI were identified and included in the study. Subjects and Methods: Retrospective analysis of clinical, angiographic and procedural characteristics as well as management and outcome of coronary artery perforation was done. Statistical Analysis Used: The whole data were tabulated, variables were presented as mean and percentages and comparison was done within them. Results: A total of 37 cases of coronary artery perforation were identified from 4532 PCI performed. Most of the coronary artery perforation belonged to Ellis Type II and Type III (both n = 15) followed by Type III CS and Type I. Lesions belonged to AHC/AHA Type C in 31 cases. Most frequent mechanism of coronary artery perforation was related to the use of guidewire and balloon (both n = 17). The total of 8 cases presented with cardiac tamponade requiring pericardiocentesis. Eleven cases required emergency covered stent implantation. In two cases microcoil was used while one case required polyvinyl alcohol particles to seal the perforation site. There was no in-hospital mortality while 30-day mortality occurred in one patient. One case was referred for emergency surgery. Conclusions: Coronary artery perforation is rare but potentially fatal complication of percutaneous coronary intervention. Complication of coronary artery perforation can be managed effectively in the catheterization laboratory without the need of emergency of bailout surgery and in-hospital outcomes remain good in the majority of cases.

Coronary artery aneurysm: Evaluation, prognosis, and proposed treatment strategies Azeem S Sheikh, Ahmed Hailan, Tim Kinnaird, Anirban Choudhury, David Smith Heart Views 2019 20(3):101-108 Coronary artery aneurysm is a rare disorder, which occurs in 0.3%–4.9% of patients undergoing coronary angiography. Atherosclerosis accounts for >90% of coronary artery aneurysms in adults, whereas Kawasaki disease is responsible for most cases in children. Recently, with the advent of implantation of drug-eluting stents, there are increasing reports suggesting stents causing coronary aneurysms, months or years after the procedure. The pathophysiology of coronary artery aneurysm is not completely understood but is thought to be similar to that for aneurysms of larger vessels, with the destruction of arterial media, thinning of the arterial wall, increased wall stress, and progressive dilatation of the coronary artery segment. Coronary angiography remains the gold standard tool, providing information about the size, shape, and location and is also useful for planning the strategy of surgical resection. The natural history and prognosis remain unclear. Despite the important anatomical abnormality of the coronary artery, the treatment options of coronary artery aneuryms are still poorly defined and present a therapeutic challenge. We describe four cases, which were managed differently followed by a review of the current literature and propose some treatment strategies.

Right coronary artery stent dislodgment during primary percutaneous coronary intervention. To leave or to retrieve? Dawoud Ibrahim Al Kindi, Fahad Abdullah Al Kindi Heart Views 2019 20(3):109-113 Coronary stent dislodgment and embolization are rare and challenging complications of percutaneous coronary intervention that may result in serious and fatal complications attributed to the loss of blood flow of the coronary, cerebral, or peripheral circulations. Percutaneous management is successful in most cases using different techniques and devices, but surgery may be required. We report two cases of stent dislodgment during primary PCI for the right coronary artery with different management approaches and outcomes.

Left ventricular pseudoaneurysm: A diagnostic dilemma Khandaker Mohammam Azizul Hasan, Panduranga Prashant Heart Views 2019 20(3):114-117 Cases of infective endocardits presenting per se as huge LV PA are rarely reported in the literature. A 30-year-old male with no cardiac risk factors presented with community-acquired pneumonia and sepsis and shock. Chest X-ray revealed bilateral consolidation. A huge bulge was noted on the left ventricular border. Electrocardiogram did not reveal any ischemia or infarction. A transthoracic echocardiogram showed an aneurysm-like structure communicating with the left ventricle free wall below the mitral valve suggestive of LV pseudoaneurysm with severe mitral regurgitation. This was confirmed by a computed tomography scan. No vegetation was noted. He was treated aggressively with intravenous broad-spectrum antibiotics and inotropes but was in persistent shock. Cardiac surgery was considered, but the patient and relatives refused. Finally, he went into refractory shock and expired. The dilemma was the cause for this presumably acute-onset PA. There was no clear-cut evidence of endocarditis, though this appears to be the etiology in this patient.

Twiddler's syndrome: An unusual cause of repeated shocks by implantable cardioverter-defibrillator in an asymptomatic patient Ahmad Jabri, Zenab Laiq, Yassar Nabeel Heart Views 2019 20(3):118-121 Twiddler's syndrome refers to malfunction of pacemaker or implantable cardioverter-defibrillator (ICD) resulting from deliberate or unintentional twisting of pulse generator in device pocket, resulting in lead dislodgment. We report a case of a 65-year-old woman with multiple ICD shocks and antitachycardia pacing events on device interrogation, while she was unaware of the ICD discharges. Twiddler's syndrome is rare and mostly occurs in obese or elderly because of loose subcutaneous tissue allowing pulse generator to rotate in its pocket. It can be prevented by patient education against hand manipulating the generator. Smaller device pocket or suturing generator to fascia can also prevent future episodes.

Kounis syndrome: A more commonly encountered cause of acute coronary syndrome Christina RodrÍguez-Ruiz, Gisela Puig-Carrión, Andrea Delgado-Nieves, Angel López-Candales Heart Views 2019 20(3):122-125 Kounis syndrome (KS) has been defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults. It was thought to be a rare condition but is now being more commonly identified as the cause of acute coronary events in patients without previous history of coronary artery disease (CAD). The most identified KS cases have been provoked by medications on elderly male patients. The purpose of this case report is to describe an unusual case of KS, triggered by a food allergen in a young female patient. This case reminds us that it is important to have a high index of suspicion, particularly in MI patients presenting without previous history of CAD. In this manner, an appropriate management, considering both cardiac and allergic components of KS, can be given without further delay and progression of symptoms.

Anomalous left coronary artery from pulmonary artery Gopal Chandra Ghosh, John Jose, Kunal Gururani Heart Views 2019 20(3):126-127