Objective: Distal transradial access (TRA) has been recently introduced as an alternative access site for coronary angiography (CAG). Both procedures can be performed in cardiology clinics by interventional cardiologists. Although distal TRA is considered to be more difficult as it requires artery puncture and experienced cardiologists, it seems to be more advantageous because of the limited risk of arterial occlusion. In this study, we share our experiences with distal TRA and conventional TRA.
Methods: Seventy patients undergoing CAG via distal TRA and 63 patients via conventional TRA were included in this study. The patients’ data were reviewed retrospectively and compared in terms of procedural characteristics and complications.
Results: There was no significant difference between the distal TRA group (94.2%) and the conventional TRA group (98.4%) in terms of success rate (p=0.217). In the distal TRA group, the total sheath emplacement time was longer (p<0.001), and hemostasis time was shorter (p<0.001) compared with conventional TRA. Total procedural time and hospitalization period were not statistically different between the groups (p>0.05). Radial spasm and radial occlusion were more common in the conventional TRA group than in the distal TRA group (7.9% vs 1.4% and 3.1% vs 1.4%, respectively), and hematomas were not statistically different between the groups.
Conclusion: Although distal TRA seems more advantageous in terms of less hemostasis time and less vascular complications, it takes a longer time for sheath insertion and may cause more pain, which may diminish its efficiency. Large-scale studies are needed to address this issue.

Objective: Left ventricular (LV) systolic function measured through LV ejection fraction (LVEF) has prognostic implications in patients with cardiac and non-cardiac conditions. The balance of thiol and disulphide levels reflects oxidative status in the body. In this study, we aimed to investigate the relationship between plasma thiol and disulphide levels, and LVEF calculated by transthoracic echocardiography (TTE).
Methods: This retrospective study included 1,048 patients referred for TTE examination and biochemical analyses, including plasma thiol and disulphide levels. After the application of exclusion criteria, the remaining 611 patients were included in the statistical analysis. Patients were classified into two groups, namely normal LVEF (n-LVEF) (n=446) and low LVEF (l-LVEF) (n=165) according to a cut-off level of LVEF 50%. To reduce sample selection bias and adjust for the influence of differences in patient characteristics on LVEF and oxidative status, 1: 1 propensity score matching analysis was applied.
Results: Propensity score matching analysis yielded 125 patients in both groups with comparable demographics, medications, and blood parameters. Native thiol and total thiol levels were lower in l-LVEF patients than in n-LVEF patients (p<0.001 for both), whereas disulphide levels were higher in l-LVEF group (p=0.008). Native thiol (r=0.384, p<0.001), total thiol (r=0.35, p<0.001), and disulphide levels (r=-0.129, p=0.004) significantly correlated with LVEF.
Conclusion: Plasma thiol levels decrease and disulphide levels increase suggesting the presence of oxidative stress in patients with l-LVEF. Significant correlation between oxidative stress and LVEF sheds light about the possible pathogenetic role of thiol and disulphide in heart failure.

Objective: The current understanding of heart failure (HF) largely centers round left ventricular (LV) function; however, disorders in serial integration of cardiovascular system may cause a hemodynamic picture similar to left-sided HF. Therefore, focusing only on LV function may be a limited and misleading approach. We hypothesized that cardiovascular system has four major integration points, and disintegration in any of these points may produce the hemodynamic picture of HF.
Methods: We used a computational model in which mechanical properties of each chamber were characterized using time-varying elastance, and vascular beds were modeled by series of capacitances and resistances. The required percent changes in stressed volume (Vstressed) was presented as a measure of congestion susceptibility.
Results: As mean systemic pressure is closely correlated with pulmonary capillary wedge pressure (PCWP), arteriovenous disintegration can create a diastolic dysfunction pattern, even without any change in diastolic function. For 10%, 20%, 30%, 40%, and 50% interventricular disintegration, required Vstressed for reaching a PCWP over 20 mmHg was decreased by 42.0%, 31.2%, 22.5%, 15%, and 8.3%, respectively. Systolodiastolic disintegration, namely combined changes in the end-diastolic and systolic pressure-volume curves and ventriculoarterial disintegration significantly decreases the required percent change in Vstressed for generating congestion.
Conclusion: Four disintegration points can produce the hemodynamic picture of HF, which indicates that combination of even seemingly mild abnormalities is more important than an isolated abnormality in a single function of a single chamber. Our findings suggest that a “cardiovascular disintegration” perspective may provide a different approach for assessing the HF syndrome.

Objective: To compare the prevalence of hypertension and pre-existing use of renin-angiotensin-aldosterone system blockers in patients with coronavirus disease (COVID-19) and non-COVID-19 viral pneumonias.
Methods: Real-time polymerase chain reaction confirmed COVID-19 and non-COVID-19 pneumonia patients were retrospectively analyzed. The presence of hypertension, coronary artery disease (CAD), and pre-existing use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) were compared between the groups.
Results: A total of 103 COVID-19 and 91 non-COVID-19 hospitalized viral pneumonia patients were enrolled. Hypertension and CAD were more common in patients with non-COVID-19 viral pneumonia than in patients with COVID-19 (39.6% vs 22.3%, respectively, p=0.012 and 24.2% vs 4.9%, respectively, p<0.001). In our study, 2.9% and 6.8% of patients with COVID-19 were on ACEIs and ARBs, respectively, whereas 13.2% and 19.8% of patients with non-COVID-19 viral pneumonia were on ACEIs and ARBs, respectively (p=0.009 and p=0.013). Neutrophil-to-lymphocyte ratio (p<0.001) was prominent in patients with non-COVID-19 viral pneumonia compared with patients with COVID-19.
Conclusion: Our study results indicate that hypertension and CAD are more common among patients with non-COVID-19 viral pneumonia than patients with COVID-19. The prevalence of ACEIs and ARBs use was not higher in patients with COVID-19. Our results support that the use of ACEIs and ARBs do not play a specific role in patients with COVID-19.

Objective: Acute ischemic cardiac events can complicate coronavirus disease 2019 (COVID-19). We report the in-hospital characteristics of patients with acute myocardial infarction and concomitant COVID-19.
Methods: This was a registry-based retrospective analysis of patients admitted with positive COVID-19 tests who suffered acute myocardial infarction either before or during hospitalization; from 1 March 2020 to 1 April 2020 in a tertiary cardiovascular center—Tehran Heart Center. We performed an exploratory analysis to compare the clinical characteristics of patients who died during hospitalization or were discharged alive.
Results: In March 2020, 57 patients who had acute myocardial infarction and a confirmed diagnosis of COVID-19 were included in the study. During hospitalization, 13 patients (22.8%) died after a mean hospital stay of 8.4 days. The deceased were older than the survivors. No significant association between mortality and sex or length of hospital stay was observed. Hypertensive individuals were more likely to have a fatal outcome. Previously receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers did not show any association with mortality. Regarding the laboratory data during hospitalization, higher cardiac troponin T, neutrophil count, C-reactive protein, urea, and blood urea nitrogen/creatinine ratio were observed in the mortality group. The deceased had a lower lymphocyte count than the survivors.
Conclusions: Markers of worsening renal function and immune system disturbance seem to be associated with mortality in concurrent acute myocardial infarction and COVID-19. Optimizing the management of acute coronary syndrome complicating COVID-19 requires addressing such potential contributors to mortality.

Objective: Previous studies have shown cesarean section (C-section) and antibiotic use in the infantile period lead to chronic diseases in later life. It is also known that breastfeeding, which forms the basal system of immunity, is a protector in neonates. In this study, we aimed to investigate the association between breastfeeding, antibiotic use, C-section, and premature atherosclerosis.
Methods: A total of 100 patients who underwent coronary angiography and had stenosis in at least 1 epicardial vessel and 100 controls with normal coronaries were included in the study. In addition to traditional risk factors, type of delivery, breast milk intake and duration, and antibiotic use and frequency were evaluated for each participant. Lipid profile was added to the study procedure. Angiographic images of the study groups were examined to calculate the Gensini score.
Results: Smoking, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and family history were different between the groups. In the control group, 3 were born via C-section, whereas 26 were born via C-section in the atherosclerosis group (p<0.001). Breast milk intake and duration was also significantly higher in the control group (p=0.018). Antibiotic use was less in the control group, but there was no statistically significant difference (p=0.099). In multivariate logistic regression analysis, diabetes mellitus, smoking, and C-section were predictors of atherosclerosis (p=0.036, p=0.001, and p=0.003, respectively). In receiver operating characteristics curve analysis, the ability of C-section to predict premature atherosclerosis was superior to diabetes but not to smoking (area under curve, 0.607; p=0.023).
Conclusion: Mode of delivery and breast milk intake should be evaluated and considered among the risk factors of premature atherosclerosis.

Objective: The prevalence of obesity is increasing globally. Obesity has been shown to be associated with adverse cardiac outcomes. Current knowledge on the impairment of cardiac function caused by obesity in young adult population is lacking. Therefore, we aimed to evaluate the effect of obesity on cardiac deformation parameters in healthy obese individuals in early adulthood using 2D deformation imaging and 3D echocardiography.
Methods: Seventy-seven volunteers with a body mass index (BMI) above 25 kg/m2 who were between 18 and 30 years of age and a control group including 40 participants were included. Patients with a history of organic heart disease, poor image quality, or current pregnancy were excluded. Participants were classified as overweight (BMI of 25-29.9 kg/m2) and obese (BMI ≥ 30 kg/m2). Two dimensional and 3D appropriate echocardiographic images were recorded and further analyzed with a post-processing software to obtain the global longitudinal strain (GLS) of left (LV) and right ventricle (RV).
Results: A total of 117 subjects without metabolic syndrome were enrolled. Conventional dimensional and functional parameters as well as 3D volumetric measurements showed no significant differences among the groups. Presence of epicardial fat tissue was higher in the obese group. Notable differences were found among the groups for both 2D speckle tracking derived and 3D LV GLS, RV GLS, RV free-wall LS (analysis of variance [ANOVA], p<0.05) showing lower deformation in obese subjects. LV torsion was found to be significantly higher (ANOVA, p<0.05) for the obese group.
Conclusion: Obesity causes subclinical dysfunction of LV and RV in healthy obese subjects in early adulthood. Risk stratification should be performed by considering possible mentioned impact of obesity on myocardial functions.

In recent years, percutaneous transluminal angioplasty has become the preferred revascularization option for chronic limb-threatening ischemia (CLTI) and infrapopliteal (IP) arterial disease. CLTI and IP disease require complex and lengthy procedures that necessitate multiple balloon inflations and frequent contrast injections. It will lead to severe discomfort if periprocedural pain control is inadequate. Conventional methods such as local anesthesia and systemic opioids are usually inadequate to provide pain control for complex IP arterial disease interventions. Ultrasound-guided peripheral nerve blockade (PNB) has been recently employed in peripheral procedures, with several small studies reporting favorable results in patients who underwent not complex interventions. In the present series, we report our experience of 4 patients who underwent PNB to relieve pain during endovascular treatment of complex IP disease, and in whom we have observed excellent periprocedural pain control that led to satisfactory postprocedural outcomes.

The occurrence of acute coronary syndrome (ACS) following a scorpion sting has been very rarely reported in literature, and most of the cases presented had a normal coronary angiogram. The possible pathogenetic mechanisms include imbalance in blood pressure and coronary spasm caused by a combination of sympathetic excitation with subsequent thrombosis of coronary vessels developed after the release of vasoactive, inflammatory, and thrombogenic substances contained in the scorpion venom. In this report, we present a case of a scorpion sting complicated by ACS, called Kounis syndrome (KS). His coronary angiogram revealed the presence of significant stenosis of the left anterior descending artery. He was treated successfully with percutaneous transluminal coronary angioplasty, antivenom serum, and supportive therapy.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global coronavirus disease 2019 (COVID-19) pandemic. Although the virus predominantly causes respiratory system infection, recent reports have shown that it is also associated with many cardiovascular complications. It has been reported that COVID-19 may cause myocarditis, type 1 and 2 acute myocardial infarction, and thrombotic complications.[1] Spontaneous coronary artery dissection (SCAD) is a rare form of coronary artery disease that has recently been associated with COVID-19 in a few case reports. The case reported here is of COVID-19 associated SCAD in a patient with no history of cardiovascular disease.