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Background Periprocedural myocardial injury is a predictor of cardiovascular morbidity and mortality after percutaneous coronary intervention. Methods The authors examined the effects of preprocedural lipid levels (low-density lipoprotein, high-density lipoprotein, and triglycerides) in 977 patients with coronary artery disease who underwent elective percutaneous coronary intervention. Results Elevated cardiac troponin I level (≥5× the upper limit of normal) was used to indicate periprocedural myocardial injury. Serum lipid samples were collected 12 hours preprocedurally. Cardiac troponin I was collected 1, 6, and 12 hours postprocedurally. Correlations between preprocedural lipid levels and postprocedural cardiac troponin I were studied. Low-density lipoprotein levels were less than 70 mg/dL in 70% of patients and greater than 100 mg/dL in only 7.4% of patients; 13% had triglyceride levels greater than or equal to 150 mg/dL, and 96% had high-density lipoprotein levels less than 40 mg/dL. Patients with elevated cardiac troponin I had significantly lower left ventricular ejection fraction than did those with cardiac troponin I levels less than 5× the upper limit of normal (P = .01). Double-and triple-vessel disease were more common in patients with elevated cardiac troponin I (P < .002). Multivariable logistic and linear regression analyses revealed no statistically significant associations between lipid levels and postprocedural cardiac troponin I elevation, possibly because such large proportions of included patients had low levels of low-density lipoprotein (70%) and a history of statin intake (86%). Conclusion The authors found no association between lipid profile and periprocedural myocardial injury.

There has been a revolution in the management of type B aortic dissection (TBAD) over the last two decades due to the increasing development of endovascular techniques, with the prime example being thoracic endovascular aortic repair (TEVAR). However, many controversies concerning the use of TEVAR in TBAD exist. For instance, there is little available evidence suggesting any differences in demographics, disease characteristics, intervention technicalities and clinical outcomes between males and females as well as different ethnicities when undergoing TEVAR for TBAD, both in the short and long-term. Also, there is no risk prediction model/tool available.The objective of this international study is to describe and delineate the disparities between male and female patients of different ethnicities in terms of demographics, disease and interventional characteristics, and clinical outcomes.Over 17 years a total of 58 TBAD patients were admitted to two tertiary vascular centres and treated using TEVAR. Mortality, post-operative complications and reintervention data were recorded for the first 30 days after the procedure as well as during follow-up. Follow-up for all patients lasted until the study endpoint or until a patient's death. Data was analysed retrospectively using IBM SPSS 26 for Windows.Mean age was similar between the two groups, with the majority of patients in both being Caucasian. More than half of the males had complicated TBAD, whilst the majority of females were classed as having uncomplicated disease. The most commonly utilised proximal and distal landing zone for the TEVAR stent-graft was zone 2 and zone 4, respectively. The mean proximal stent diameter was significantly larger in males compared to females (p=0.004). The difference in mean distal diameter between the two groups was insignificant (p=0.721). The mean total stent coverage of the thoracic aorta was 251.3 mm in male patients compared to 291.2 mm in females (p=0.203). A total of 32 patients underwent adjunctive procedures. Seven (17%) of the males had one or more post-operative complications compared to 2 (12%) females. Nine (22%) males underwent a reintervention procedure post-TEVAR compared to only 1 (6%) female (p=0.136). Overall, males had a mortality rate of 24% (n=10) compared to 41% of females (n=7) (p=0.201). Estimated survival of males and females post-TEVAR was 80.4 ± 9.6 months and 69.7 ± 14.4 months (p=0.428). For the total population, the number of stent-grafts was inversely correlated with mortality.Despite the favourable clinical outcomes achieved by TEVAR in TBAD, there remains a grey area concerning its management. Thus, it is important to perform risk stratification of individual patients using their demographics and comorbidities, particularly scrutinizing gender and ethnic origin when considering intervention for TBAD to achieve optimum results.

COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non–COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.

Data suggest that COVID-19 results in a prothrombotic state leading to arterial/venous thrombosis. Vaccination, novel antiviral drugs, and emerging variants have changed the course of the disease in many ways; however, their effects on the incidence of thrombotic events and the efficacy of preventative antithrombotic agents have not been yet evaluated. A systematic search was conducted to identify studies reported the incidence of thrombotic events based on vaccination status, use of novel antiviral drugs, and emerging viral variants. Similarly, we screened the ongoing/published randomized trials of preventative antithrombotic therapy in any COVID-19 population to assess whether subgroup-specific results were reported based on any of these variants. Upon searching a total of 3451 records, only one entry fulfilled the inclusion criteria of our systematic review, which was a self-controlled case series on 29,121,633 vaccinated individuals, the incidence rate ratio of thrombotic complication after breakthrough infection was 13.86, 95% CI, 12.76 to 15.05 compared to 1.10, 95% CI, 1.02 to 1.18, during the 28-day postvaccination. In conclusion, although the mortality benefit of mass vaccination and the early promising results of the new antiviral therapies are well-known, we were unable to find clinical evidence on whether vaccination, the use of novel antiviral agents, and emerging viral variants have affected the incidence rate of thrombotic events or impacted the efficacy of prophylactic antithrombotic therapy in patients with COVID-19. Analyses from existing trials and large-scale registries can provide interim knowledge and any findings of relevance should be incorporated in the design of future trials.

Background We sought to estimate the prevalence of diabetes mellitus (DM) and pre-DM and their associated factors among a sample of the Iranian urban population between 2017 and 2019. Methods The present investigation is a sub-study on the HAMRAH cohort study, a longitudinal population-based cohort study to assess the 10-year risk of cardiovascular diseases and their related risk factors in the adult population of the Iranian capital, Tehran. Via a multistage cluster randomized sampling method, 2123 adults aged between 30 and 75 years who had no history of cardiovascular diseases were selected for the study. With the aid of the 2010 American Diabetes Association criteria for the definition of DM and pre-DM, age and sex-specific prevalence rates were estimated. Results The estimated overall prevalence of DM was 14.3% (95% CI: 13.1%–15.8%): 10.4% known DM (95% CI: 9.1%–11.8%) and 4% newly diagnosed DM (95% CI: 3.1%–5.1%). Pre-DM was detected in about 29.2% of the study participants (95% CI: 22.9–36.3%). Our logistic regression analysis revealed that increasing age, higher systolic blood pressure, higher levels of triglycerides, and lower levels of high-density lipoprotein were significantly associated with DM. Conclusions DM and pre-DM follow a notable incremental pattern among the Iranian urban population. This finding underscores the significance of the need to improve prevention and screening strategies in the Iranian urban population.

Background: One of the most common and treatable causes of stroke is carotid artery stenosis. Carotid artery stenting (CAS) is an option for treating the stenosis, with such notable clinical outcomes as low rates of in-hospital death, stroke, and intracerebral hemorrhage.Methods: All patients who underwent carotid angioplasty between December 2010 and January 2019 in Rajaie Cardiovascular Medical and Research Center were enrolled. The incidence rates of major adverse cardiac and cerebral events (MACCE), defined as a composite of stroke, myocardial infarction, bleeding, and all-cause mortality, both during hospitalization and at long-term follow-up were determined. Results: A total of 380 patients, 264 (69.5%) symptomatic and 116 (30.5%) asymptomatic, were included. The mean age of study population was 68.6 ± 10.6 years. During post-CAS in-hospital course, stroke occurred in 2 (0.5%), intracranial hemorrhage in 4 (1.1%), death in 2 (0.5%) and MACCE in 8 (2.1%) in symptomatic, and stroke in 1 (0.3%), intracranial hemorrhage in 1 (0.3%), death in 1 (0.3%) and MACCE in 3 (0.8%) in asymptomatic patients. Totally, stroke occurred in 3 (0.8%), intracranial hemorrhage in 5 (1.3%), death in 3 (0.8%), and MACCE in 11 (2.89%) patients.Long-term follow-up (40.95 ± 15.81 months) was performed on 295 (77.6%) patients; the results demonstrated a mortality rate of 13.9% (n = 41) which 30 (10.1%) cases belonged to symptomatic and 11 (3.7%) cases were from asymptomatic patients. Stroke happened in 26 (8.8%), that 18 (6.1%) cases were symptomatic and 8 (2.7%) cases were asymptomatic. MACCE rate was 19.3% (n = 57) which 41 (13.8%) cases were symptomatic and 16 (5.4%) were asymptomatic. Age (OR: 1.040, 95% CI: 1.002 to 1.079) was confirmed as a meaningful variable for the occurrence of MACCE. Conclusions: Our results confirm the safety and efficacy of carotid stenting in experienced centers. Age was as an important predictor of all-cause mortality, myocardial infarction, and MACCE.

Background Screening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran. Methods A Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients’ medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer’s perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses. Results The mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran. Conclusions The results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Background Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear. Objectives The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre–COVID-19 cohorts. Methods From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019). Results In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p, Central Illustration

Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiological features of coronavirus disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of illness severity of COVID-19. A variety of antithrombotic agents, doses, and durations of therapy are being assessed in ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and patients critically ill with COVID-19. This paper provides a perspective of the ongoing or completed RCTs related to antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of existing knowledge, as well as data gaps that may motivate the design of future RCTs.

Background Little evidence is available on post-pulmonary embolism impairment (PPEI), a recently defined complication of pulmonary embolism (PE) encompassing dysfunctional clinical and imaging parameters. In the present study, we sought to evaluate its frequency with a focus on the main components. Methods In this prospective registry, we included patients with a confirmed diagnosis of acute PE and focused on those with initial right ventricular (RV) dysfunction. Their baseline, pre-discharge, and 6 month follow-up clinical and imaging characteristics were recorded. The main study outcomes were incomplete RV functional recovery, exercise capacity limitations (based on the 6 minute walk test), and their combination, which defines PPEI, within six months of acute PE. Results Of 170 consecutive patients with a confirmed diagnosis of acute PE, 123 accepted to participate in the follow-up study, of whom 87 had initial RV dysfunction. The 6 month rates of incomplete RV functional recovery, signs of an intermediate-to-high echocardiographic probability of PH, and exercise limitations were observed in 58.6, 32.1, and 45.9%, respectively. A total of 22 (25.2%; 95% CI 15.5-34.4%) patients had PPEI. The RV/LV ratio and the fractional area change on discharge after acute PE were more often impaired among patients with incomplete RV recovery, exercise limitations, and a high probability of PH at 6 months. In contrast, an initial impaired RV diastolic function indices appeared to characterize patients with a limited exercise capacity at 6 months. Discussion PPEI affects one fourth of patients surviving acute PE with half of them presenting with RV dysfunction or exercise limitations.

Intramural hematoma of the esophagus (IHE) represents a rare condition on the spectrum of esophageal injuries. The most common symptoms are hematemesis, epigastric pain or retrosternal chest pains, odynophagia, and dysphagia. Early recognition of IHE is important as it may mimic other diseases such as myocardial infarction, pulmonary embolism, Mallory–Weiss tears, Boerhaave’s syndrome, ruptured aortic aneurysms, and aortic dissection. Computed tomography is the preferred investigation method, and treatment is usually conservative. We herein present 2 cases of IHE associated with catheter-directed thrombolysis in the setting of pulmonary embolism.

A 70-year-old man with a history of coronary artery bypass grafting 15 years back and arteriovenous (AV) fistula creation in the left arm 1 month back presented with acute coronary syndrome (ACS). He had not received dialysis before his referral. We felt the most likely etiology for these complaints was increased cardiac oxygen demand from an increased cardiac output related to the newly formed left AV fistula. Coronary angiography was done to detect any significant stenosis in the native or grafted vessels. This revealed that the left subclavian artery was totally occluded in the ostioproximal segment and the coronary arteries did not have occlusions to explain the ACS setting. CT angiography confirmed the angiographic findings of the totally occluded left subclavian artery followed by a well-developed and patent left internal mammary artery to left anterior descending artery. This led to the consideration of a steal syndrome from the coronary artery by the subclavian artery distal to the occlusion. A successful percutaneous endovascular intervention on the left subclavian artery occlusion was performed. Subsequently, the patient became asymptomatic and experienced a dramatic increase in left ventricular ejection fraction.

Background Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown. Methods The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count 3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts. Conclusions INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19., Highlights • The optimal anticoagulant regimen for critically-ill patients with COVID-19 remains unknown. • It is unknown if pleiotropic effects of statins may reduce thromboinflammation in COVID-19. • This manuscript summarizes the rationale and methodology of the INSPIRATION and INSPIRATION-S studies. • The manuscript provides a summary about other anticoagulation trials and statin trials in COVID-19.

The concomitant occurrence of acute type B aortic dissection (TBAD) and acute pulmonary embolism (PE) is a rare but challenging condition. Although anticoagulation therapy is essential in the treatment of PE, it may increase the risk of aortic rupture and bleeding complications. We herein describe a patient with acute TBAD complicated by PE, which was successfully treated with early thoracic endovascular aortic repair (TEVAR) followed by anticoagulation. The present case report demonstrates that early TEVAR not only treats the aortic pathology but also allows the safe initiation of anticoagulation therapy.

Given the nature of heart disease and the importance of continuing heart surgery during the pandemic and its aftermath and in order to provide adequate safety for the surgical team and achieve the desired result for patients, as well as the optimal use of ICU beds, the medical team, blood, blood products, and personal protective equipment, it is essential to change the usual approach during the pandemic. There are still a lot of evidences and experiences needed to produce the perfect protocol. Some centers may have a special program for their centers during this period of epidemics that can be respected and performed. Generally, in pandemic conditions, the use of non-surgical approaches is preferred if similar outcomes can be obtained.

Coronavirus disease of 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is spreading rapidly the world over. The disease was declared "pandemic" by the World Health Organization. An approved therapy for patients with COVID-19 has yet to emerge; however, there are some medications used in the treatment of SARS-CoV-2 infection globally including hydroxychloroquine, remdesivir, dexamethasone, protease inhibitors, and anti-inflammatory agents. Patients with underlying cardiovascular disease are at increased risk of mortality and morbidity from COVID-19. Moreover, patients with chronic stable states and even otherwise healthy individuals might sustain acute cardiovascular problems due to COVID-19 infection. This article seeks to review the latest evidence with a view to explaining possible pharmacotherapies for the cardiovascular complications of COVID-19 including acute coronary syndrome, heart failure, myocarditis, arrhythmias, and venous thromboembolism, as well as possible interactions between these medications and those currently administered (or under evaluation) in the treatment of COVID-19.

Highlights Abstract Background and Objectives: Dialysis-access troubleshoots cause a large number of admissions and impose a considerable amount of cost on both patients and health care systems. The reasons for late access-site failure include neointimal hyperplasia, outflow tract remodeling and fibrosis, and multiple catheterizations via the central veins. Drug-coated balloons (DCBs), high-pressure balloons, high radial force self-expanding stents, and covered stents have been shown to have good long-term access failure-free survival after the first intervention in previous studies. This study aimed to evaluate the effect of endovascular treatment on dialysis-access durability in the era of DCBs. Methods: Patients who underwent endovascular treatment for the failure of any dialysis-access type—including arteriovenous fistulae, arteriovenous grafts, and central vein catheters—between October 2016 and March 2018 were recruited in the present study. Procedural and follow-up data were gathered and analyzed. Results: Within 17 months, 47 endovascular procedures were performed. Among them, 37 (78.7%) procedures were conducted as de novo procedures and the rest were reinterventions. All reinterventions were conducted on cases with central vein stenoses or occlusions (10 [21.3%] procedures). Conclusion: The reintervention rate is higher in central vein obstruction among patients with dialysis access. Higher rates of flow and previous catheterizations cause intimal hyperplasia and vascular remodeling. Newer devices, including larger DCBs, may reduce the rate of reintervention in these lesions.

In patients undergoing mitral valve repair (MVre), a 3-month course of anticoagulation is currently recommended. The role of the non-vitamin K antagonist oral anticoagulants has here been scarcely studied. In the present mixed cohort study, the safety and efficacy of rivaroxaban (prospective analysis) were compared with those of warfarin (retrospective analysis) in patients undergoing MVre. Anticoagulation therapy was continued for at least 3 months, and the patients were followed for 1 year following surgery. The present study recruited 736 patients undergoing MVre with or without concomitant coronary artery bypass or surgical repair on the other valves. Concomitant valvular replacement and severe chronic kidney diseases were the most important exclusion criteria. The final analysis was conducted on 153 patients treated with rivaroxaban and 144 patients treated with warfarin. Dissimilarities in baseline characteristics necessitated propensity score matching, in which 104 patients in each group were compared. No major bleeding or cerebrovascular accident occurred during the 1-year follow-up. Clinically relevant non-major bleeding was reported in 2 patients in the rivaroxaban group and 4 patients in the warfarin group, a difference non-statistically significant before and after propensity score matching (P = 0.371 and P = 0.407, respectively). The type of anticoagulation did not predict the 1-year outcome (HR 2.165, 95% CI 0.376 to 12.460; P = 0.387). In this mixed cohort study, rivaroxaban was both safe and efficient in patients with MVre. Such preliminary results should prompt larger randomized controlled trials.

Background and Objectives: Cardiovascular diseases (CVDs) impose great burden on the health systems worldwide. The prevention of CVDs depends on the correct information about the perveance/incidence of them and their determinants in the community and population-based studies are the most accurate ways for obtaining these data. The objective of this study is to determine the prevalence of the classic risk factors of CVDs among healthy adult residents of Tehran and their changes through a 10-year follow-up in Tehran, the capital of Iran. This article presents the study protocol. Methods: Heart Assessment and Monitoring in RAjaie Hospital, is a population-based study conducted in Rajaie Cardiovascular Medical and Research Center, the largest tertiary care hospital for CVDs in Tehran. It consists two phases: A survey and a prospective cohort. People between 30 and 75 years of age, without known CVDs, invite through a multistage random sampling process. They will assess for the CVD risk factors, laboratory indices, electrocardiography and echocardiography features, diet, physical activity levels, psychological aspects, and peripheral vascular diseases. All the participants will be followed for 10 years and the changes in the above-mentioned factors and incidence of CVDs assessed. Discussion: It is expected that through obtaining valid, population-specific data, the information for policy making and efficient management of CVDs in Iranian people be provided.

Bioprosthetic valve thrombosis is a growing recognized entity, especially with the increasing use of the valve in vale procedures and the advent of new detection technologies (e.g., 4D CT and 4D echocardiography). However, the optimal management strategy in the acute context is not established. This paper presents a case of early thrombosis following the percutaneous tricuspid valve in vale procedure that was successfully managed with thrombolysis.

Objective To assess the effect of statin treatment versus placebo on clinical outcomes in patients with covid-19 admitted to the intensive care unit (ICU). Design INSPIRATION/INSPIRATION-S was a multicenter, randomized controlled trial with a 2×2 factorial design. Results for the anticoagulation randomization have been reported previously. Results for the double blind randomization to atorvastatin versus placebo are reported here. Setting 11 hospitals in Iran. Participants Adults aged ≥18 years with covid-19 admitted to the ICU. Intervention Atorvastatin 20 mg orally once daily versus placebo, to be continued for 30 days from randomization irrespective of hospital discharge status. Main outcome measures The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or all cause mortality within 30 days from randomization. Prespecified safety outcomes included increase in liver enzyme levels more than three times the upper limit of normal and clinically diagnosed myopathy. A clinical events committee blinded to treatment assignment adjudicated the efficacy and safety outcomes. Results Of 605 patients randomized between 29 July 2020 and 4 April 2021 for statin randomization in the INSPIRATION-S trial, 343 were co-randomized to intermediate dose versus standard dose prophylactic anticoagulation with heparin based regimens, whereas 262 were randomized after completion of the anticoagulation study. 587 of the 605 participants were included in the primary analysis of INSPIRATION-S, reported here: 290 were assigned to atorvastatin and 297 to placebo (median age 57 years (interquartile range 45-68 years); 256 (44%) women). The primary outcome occurred in 95 (33%) patients assigned to atorvastatin and 108 (36%) assigned to placebo (odds ratio 0.84, 95% confidence interval 0.58 to 1.21). Death occurred in 90 (31%) patients in the atorvastatin group and 103 (35%) in the placebo group (odds ratio 0.84, 95% confidence interval 0.58 to 1.22). Rates for venous thromboembolism were 2% (n=6) in the atorvastatin group and 3% (n=9) in the placebo group (odds ratio 0.71, 95% confidence interval 0.24 to 2.06). Myopathy was not clinically diagnosed in either group. Liver enzyme levels were increased in five (2%) patients assigned to atorvastatin and six (2%) assigned to placebo (odds ratio 0.85, 95% confidence interval 0.25 to 2.81). Conclusions In adults with covid-19 admitted to the ICU, atorvastatin was not associated with a significant reduction in the composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or all cause mortality compared with placebo. Treatment was, however, found to be safe. As the overall event rates were lower than expected, a clinically important treatment effect cannot be excluded. Trial registration ClinicalTrials.govNCT04486508.

COVID-19 is now appreciated as a pandemic, presenting with a wide range of symptoms, mostly respiratory, yet involving other organs massively. Myocardial injury is a crucial complication with significant negative impact on prognosis. Despite all the investigations, exact pathophysiologic mechanisms remain unclear, and so do the appropriate treatments. Thrombosis has been increasingly observed since the first reports, with venous thromboembolism being the major concern. The strategy of thrombosis prophylaxis, though known to be helpful to the clinical scenario, is still a subject of debate.

Background Thrombotic complications are considered among the main extrapulmonary manifestations of coronavirus disease 2019 (COVID-19). The optimal type and duration of prophylactic antithrombotic therapy in these patients remain unknown. Methods This article reports the final (90-day) results of the Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) study. Patients with COVID-19 admitted to intensive care were randomized to intermediate-dose versus standard-dose prophylactic anticoagulation for 30 days, irrespective of hospital discharge status. The primary efficacy outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause death. The main safety outcome was major bleeding. Results Of 600 randomized patients, 562 entered the modified intention-to-treat analysis (median age [Q1, Q3]: 62 [50, 71] years; 237 [42.2%] women), of whom 336 (59.8%) survived to hospital discharge. The primary outcome occurred in 132 (47.8%) of patients assigned to intermediate dose and 130 (45.4%) patients assigned to standard-dose prophylactic anticoagulation (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.95–1.55, p = 0.11). Findings were similar for other efficacy outcomes, and in the landmark analysis from days 31 to 90 (HR: 1.59, 95% CI: 0.45–5.06). There were 7 (2.5%) major bleeding events in the intermediate-dose group (including 3 fatal events) and 4 (1.4%) major bleeding events in the standard-dose group (none fatal) (HR: 1.82, 95% CI: 0.53–6.24). Conclusion Intermediate-dose compared with standard-dose prophylactic anticoagulation did not reduce a composite of death, treatment with ECMO, or venous or arterial thrombosis at 90-day follow-up.

Intravascular ultrasound (IVUS) is a widely used interventional imaging technique for the assessment of atherosclerosis plaque. Due to pulsatile heart motions, transverse and longitudinal motions are observed during in vivo pullbacks of IVUS sequences. These motion artifacts can mislead the volume-based data retrieved from IVUS studies and hinder the visualization of the vessel condition. To overcome this problem, a new fully automatic image-based gating algorithm was proposed in the current study. We utilized the phase information of the dual-tree complex wavelet transform (DT-CWT) coefficients to detect the motion of edge-like structures. For each IVUS sequence, first, six motion signals were detected by analyzing the phase of DT-CWT coefficients in six different directions. Then, the three best motion signals were selected by analyzing the frequency properties of each signal. Subsequently, these extracted signals were filtered using a modified Butterworth band-pass filter and the gated sequence was formed by using a combination of them. The proposed method was compared to four state-of-the-art methods and its frequency spectrum had more accurate characteristics in the cardiac frequency. In addition, the gated sequence extracted by the proposed method had the highest similarity to the extracted gated sequence by the physician.

Contains fulltext : 245735.pdf (Publisher’s version ) (Closed access) BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with macro- and micro-thromboses, which are triggered by endothelial cell activation, coagulopathy, and uncontrolled inflammatory response. Conventional antithrombotic agents are under assessment in dozens of randomized controlled trials (RCTs) in patients with COVID-19, with preliminary results not demonstrating benefit in several studies. OBJECTIVES: Given the possibility that more novel agents with antithrombotic effects may have a potential utility for management of patients with COVID-19, we assessed ongoing RCTs including these agents with their potential mechanism of action in this population. METHODS: We searched clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to identify RCTs of novel antithrombotic agents in patients with COVID-19. RESULTS: Based on a systematic literature search, 27 RCTs with 10 novel antithrombotic agents (including nafamostat, dociparstat, rNAPc2, and defibrotide) were identified. The results from these trials have not been disseminated yet. The studied drugs in the ongoing or completed RCTs include agents affecting the coagulation cascade, drugs affecting endothelial activation, and mixed acting agents. Their postulated antithrombotic mechanisms of action and their potential impact on patient management are summarized. CONCLUSION: Some novel antithrombotic agents have pleiotropic anti-inflammatory and antiviral effects, which may help reduce the viral load or fibrosis, and improve oxygenation. Results from ongoing RCTs will elucidate their actual role in the management of patients with COVID-19.

Background: Venous stenting plays a significant role in the treatment of acute deep vein thrombosis (DVT). But the adjuvant anti-coagulant therapy could also help to more successful patency rate. We hope to elucidate the differences in the patency rate of venous stenting with or without direct oral anticoagulants (DOAC) / non-vitamin K oral anticoagulants (NOACs). Methods: Studies that work on the stent patency rate in venous stent with or without DOAC / NOAC will be included. The primary studies (Cohort, case control, case-series or randomized/ non-randomized trials) will be included if the participants / patients have had acute or chronic DVT, with venous stenting (at least one study group or all of study subjects) who have received DOAC / NOAC agents. The stent patency rate should be reported in all of study subjects within a follow-up time, minimum for 1 year. We will perform an electronic search on published or in press articles, which have been published in MEDLINE / PubMed, Embase, the online Cochrane database, CENTRAL and searches of clinical trial registries: clinicalTrials.gov, EU Clinical Trials, ISRCTN registry, WHO network registry for trials. PROSPERO databases will be manually searched for protocols.After screening of the relevant articles, selection and data extraction will be conducted in duplicate and independently. Methodological quality of the selected studies will be assessed using the Newcastle Ottawa Scale (NOS) tool. We will use “Hazard Ratio” (HR) as the optimum Effect Size (ES) in this meta-analysis, otherwise we will use or calculate “Risk Ratio” (RR) or “Odds Ratio” (OR) ES measures as the selected study specific ES. Discussion: In this review, we hope to find the treatment failure/ success rate of venous stenting with or without DOAC / NOAC regards to the stent patency rate and will try to provide insights into the right choice of anti-coagulant therapy.Submitted to PROSPERO (20/9/2021): CRD42021274542

We present a rare case of an elderly man with degenerated bioprosthetic aortic valve complicated by infectious endocarditis 6 months after Covid-19 infection, who was treated successfully with valve-in valve after antibiotic therapy for the acute phase of infection, with excellent result and no complication early after the procedure and in follow-up visits.

The article's abstract is not available.

This study sought to compare the safety and efficacy of the balloon-expandable stent (BES) and the self-expandable stent (SES) in the endovascular treatment of coarctation of aorta.Coarctoplasty with stents has conferred promising results. Although several nonrandomized studies have approved the safety and efficacy of the BES and the SES, no high-quality evidence exists for this comparison.In the present open-label, parallel-group, blinded endpoint randomized pilot clinical trial, adult patients with de novo native aortic coarctation were randomized into Cheatham-platinum BES and uncovered nitinol SES groups. The primary outcome of the study was a composite of procedural and vascular complications. The secondary outcomes of the study consisted of the incidence of aortic recoarctation, thoracic aortic aneurysm/pseudoaneurysm formation, and residual hypertension at a 12-month follow-up.Among 105 patients who were screened between January 2017 and December 2019, 92 eligible patients (32 women [34.8%]) with a median age of 30 years (IQR: 20-36 years) were randomized equally into the BES and SES groups. The composite of procedural and vascular complications occurred in 10.9% of the BES group and 2.2% of the SES group (odds ratio: 0.18; 95% CI: 0.02-1.62; P = 0.20). Aortic recoarctation occurred in 5 patients (5.4%), 3 patients (6.5%) in the BES group and 2 patients (4.3%) in the SES group (odds ratio: 0.65; 95% CI: 0.10-4.09; P = 0.64). Only 1 patient (1.1%) was complicated by aortic pseudoaneurysm. Hypertension control was achieved in 50% of the study population, with an equal distribution in the 2 study groups at the 12-month follow-up.Both the BES and the SES were safe and effective in the treatment of native coarctation.

Background: Cardiomyopathies are characterized by structural and functional abnormalities of myocardium that will probably lead to premature death from arrhythmia and/or progressive heart failure. Myocarditis is an inflammatory disease of the myocardium diagnosed by histological criteria definitively. To date, most information about the natural history and management of cardiomyopathies and myocarditis has derived from cohort studies in a small number of specialized centers. Aim: The prevalence of patients with cardiomyopathies who referred to Rajaei Cardiovascular medical and research center from all over the country is remarkable. Rajaie Cardiomyopathy and myocarditis Registry (RCMR) study is an observational registry of consecutive patients with four cardiomyopathy subtypes: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and restrictive cardiomyopathy (RCM) as well as myocarditis designed to determine clinical characteristics, natural history, current therapeutic approaches, response to treatment and long-term outcomes of patients with cardiomyopathy and myocarditis. Prediction of mortality and response to different treatments in these patients using artificial intelligence is another aim of this registry. Covid 19 Myocarditis and its sequence as cardiomyopathy seems a new challenge in forthcoming years. Methods: Patients with a history of documented cardiomyopathy/ myocarditis fulfilling standard diagnostic criteria based on the ESC guideline for cardiomyopathy/ myocarditis and willing and able to give informed consent or in the case of child consent from a parent will be included. At baseline visit , past medical history, clinical signs/ symptoms, risk factors, physical examination and family history of cardiomyopathy, as well current standards for diagnostic workup and clinical follow-up and where relevant electrocardiogram, echocardiography, cardiac magnetic resonance, Holter monitoring, or biomarker analyses will be checked. Based on the type of disease and the physician's opinion, patients will undergo exercise test, electrophysiology study or endomyocardial biopsy. Outcome and results of various therapeutic approaches currently employed for patients including implantable cardioverter defibrillator, cardiac resynchronization therapy, septal myectomy, ablation, cardiac transplantation and medications will be assessed. Long-term outcomes including the benefits and complications of therapeutic interventions will be collected. Follow-up visit will be scheduled after 12 months for all patients and survival status, hospitalizations, co-morbidities, medications will be assessed. Data will be collected on a research electronic data source (Regitory) and will be analyzed at regular intervals based on study objectives and also by using artificial intelligence. Conclusion: RCMR aims to make a major contribution to understanding the natural history of the cardiomyopathy/ myocarditis, as well as guiding evidence-based decision making. Potential gaps with existing recommendations will be discussed as well as some suggestions for improvement of health care provision.

Objectives: The endovascular treatment (EVT) of patients with critical limb ischemia (CLI) has received considerable interest in recent years and has significantly affected the associated amputation and survival rates. Nonetheless, that this management modality may be influenced by various logistical and regional situations prompted us to design a local registry to evaluate its applicability and efficacy in our community.Methods: The IRANCLI study is a prospective, observational study that has been established as a registry. The therapeutic and follow-up protocols of this study have been approved by a multidisciplinary team. Recruited patients with CLI are followed up after in-hospital therapeutic management, endovascular revascularization, or minor amputations or debridement in cases with ulcers. The follow-up consists of active monitoring to spot patients with a recurrence of CLI signs and symptoms at early stages. Within 3 years, eligible patients are recruited to the study and are followed up for 3 years. Analyses are carried out to evaluate outcomes – comprising major adverse limb events (the primary outcome), amputation-free survival, limb salvage, event-free survival, major adverse cardiovascular and cerebrovascular events, 30 days' postprocedural adverse events, and procedural success. The predictors of procedural failure and long-term follow-up adverse events are assessed. Result and Conclusion: The IRANCLI study evaluates postendovascular revascularization outcomes and the long-term follow-up of patients with CLI. Uncovering the predictors of EVT failure and adverse events during the follow-up may improve the prospect of cases with CLI by streamlining the determination of both the patients who would benefit the most from EVT and those who would need a closer active follow-up.

A 24-year-old female patient, who had undergone stenting for aortic coarctation 4 years previously, referred to our clinic. She described some episodes of syncope and dizziness in the preceding 6 months, for which her treating neurologist had prescribed antiepileptic agents for a diagnosis of

We herein seek to expound on up-to-the-minute information regarding cardiovascular disease in the era of coronavirus disease 2019 (COVID-19) by highlighting acute myocardial injury caused by COVID-19 and probing into its pathophysiology, clinical signs, diagnostic tests, and treatment modalities. We aim to share the latest research findings vis-à-vis cardiovascular disease patients with confirmed or suspected COVID-19 on the association between hypertension and this infectious disease along with the relevant recommendations; describe the mechanism of coronary artery disease in such patients together with the necessary measures in the setting of non-ST-segment elevation acute coronary syndrome, ST-segment elevation myocardial infarction, and chronic coronary syndrome; discuss tachy- and bradyarrhythmias in the COVID-19 setting alongside their treatments; elucidate coagulopathies, venous thromboembolism, and its prophylactic measures in the context of this infection; set out the cardiopulmonary resuscitation protocol as well as the pertinent safety concerns during the current pandemic; and, finally, explicate drug-drug interactions between COVID-19 and cardiovascular medication in hypertension, acute coronary syndrome, heart failure, venous thromboembolism, and arrhythmias.

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia at which electrical stimulation does not pass a distinct pathway through heart. There are various methods to treat AF which Ablation is one of the most effective among them. The present study aimed to assess cost utility of Cryoballoon ablation (CBA) comparing to Radiofrequency ablation (RFA) to treat patients with AF in Iran.Methods: Cost utility analysis is done using a decision analytic model based on a lifetime Markov structure which was drawn considering nature of interventions and natural progress of disease. Costs data was extracted from medical records of 47 patients of Rajaie Cardiovascular Medical and Research Center in Tehran in 2019. Parameters and variables related to strategies such as transition probabilities, risks related to side effects and mortality rates as well as utility values were extracted from domestic and foreign evidences. Due to uncertainty regarding some variables used in model, deterministic and probabilistic sensitivity analysis was also done. TreeAge pro 2020 were used in all stages of analysis.Results: In the base case analysis, CBA strategy was associated with higher cost and effectiveness rather than RFA, and the incremental cost-effectiveness ratio (ICER) was $11223 per Quality adjusted life year (QALY), which compared to Iran one time GDP per capita ($7142) as Willingness to pay threshold, CBA was not cost effective. But on the other hand, considering twice the GDP per capita as threshold, CBA was cost-effective. Probabilistic sensitivity analysis confirmed findings of base case analysis, and Monte Carlo Simulation showed that RFA was cost effective by probability of 60%. One way sensitivity analysis showed that results of study has highest sensitivity to changes of RFA cost variable. The results of sensitivity analysis showed that the cost effectiveness results were not robust and are sensitive to changes in variables changes.Conclusions: Primary results showed that CBA in treatment of AF comparing to RFA is not cost-effective in Iran considering one GDP per capita. But the sensitivity analysis results showed considerable sensitivity to changes of ablation costs variable. In general, it is not possible to conclude with certainty about the cost-effectiveness of CBA against RFA.

Coronavirus disease-2019 (COVID-19) is associated with systemic inflammation, endothelial activation, and multiorgan manifestations. Lipid-modulating agents may be useful in treating patients with COVID-19. These agents may inhibit viral entry by lipid raft disruption or ameliorate the inflammatory response and endothelial activation. In addition, dyslipidemia with lower high-density lipoprotein cholesterol and higher triglyceride levels portend worse outcomes in patients with COVID-19. Upon a systematic search, 40 randomized controlled trials (RCTs) with lipid-modulating agents were identified, including 17 statin trials, 14 omega-3 fatty acids RCTs, 3 fibrate RCTs, 5 niacin RCTs, and 1 dalcetrapib RCT for the management or prevention of COVID-19. From these 40 RCTs, only 2 have reported preliminary results, and most others are ongoing. This paper summarizes the ongoing or completed RCTs of lipid-modulating agents in COVID-19 and the implications of these trials for patient management.

Importance: Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis. Objective: To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU). Design, Setting, and Participants: Multicenter randomized trial with a 2 × 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020. Interventions: Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up. Main Outcomes and Measures: The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count 3/µL). All outcomes were blindly adjudicated. Results: Among 600 randomized patients, 562 (93.7%) were included in the primary analysis (median [interquartile range] age, 62 [50-71] years; 237 [42.2%] women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% [95% CI,-6.6% to 9.8%]; odds ratio, 1.06 [95% CI, 0.76-1.48]; P =.70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% [1-sided 97.5% CI,-∞ to 3.4%]; odds ratio, 1.83 [1-sided 97.5% CI, 0.00-5.93]), not meeting the noninferiority criteria (P for noninferiority >.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% [95% CI, 0.4%-3.8%]; P =.01). Conclusions and Relevance: Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04486508.

Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiological features of coronavirus disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of illness severity of COVID-19. A variety of antithrombotic agents, doses, and durations of therapy are being assessed in ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and patients critically ill with COVID-19. This paper provides a perspective of the ongoing or completed RCTs related to antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of existing knowledge, as well as data gaps that may motivate the design of future RCTs., Central Illustration

In the coronavirus disease 2019 pandemic era, clinical programs and mandatory hands-on activities have been supplanted by remote teaching to maintain the fundamental capabilities of medical training and to furnish medical students with quality education. Nonetheless, the satisfaction of faculty members with this training method in the current pandemic has yet to be assessed. The aim of this study was to design a Persian questionnaire with appropriate validity and reliability on cardiology professors' satisfaction level with virtual education.In this cross-sectional study, a questionnaire was devised drawing upon scientific sources and Iranian medical educators' expertise. Seventeen faculty members in various specialties evaluated the questionnaire concerning face and content validity. Content validity was assessed through the calculation of the content validity ratio (CVR) (values0.62 were considered acceptable) and the content validity index (CVI) (values0.79 were considered acceptable), construct validity was evaluated through principal component factor analysis by the Kaiser-Meyer-Olkin (KMO) statistic and Bartlett's sphericity test, internal reliability was measured through the calculation of Cronbach's alpha coefficient, and consistency was appraised through the use of test-retest reliability at two different time points.The questionnaire had a reliability rate of 95%, indicating high internal validity. Concerning test-retest reliability, the intraclass correlation coefficient was 0.96 (This Persian questionnaire on virtual education aimed at cardiology faculty members in the current pandemic with its low question count and appropriate domains had high reliability and validity. By knowing the level of professors' satisfaction with the new method of education, it is possible to take steps to better provide specialized medical education to cardiology residents.

Background: Ventricular Septal Rupture (VSR) is a rare but challenging complication after myocardial infarction (MI). In the presence of acute MI, volume and pressure overload lead to acute heart decompensation. The present study was designed to evaluate the early surgical outcome of VSR for over 18 years. Method: This multicenter study was done during 2000-2018, in which 99 patients with post-MI VSR were included. Results: The patients (n=11) presenting hemodynamic deterioration at the time of hospital admission, died before any attempt for surgery. A consecutive series of 88 patients with surgical repair of VSR was evaluated. The mean interval from MI to VSR diagnosis was 7.5±7.2 days and from admission to the operation was 5±5 days. VSR location did not influence the outcome (p=0.1). The concomitant coronary bypass was done for all patients; two-vessel disease was more prevalent (39%). Only 25 patients survived and left the hospital (13 patients died in the operating room due to the failure of pump weaning and 50 patients in the ICU due to low cardiac output). Predictors of poor prognosis included low ejection fraction (p=0.01), prolonged pump time (p=0.01), and operation in the second half of this period (p=002). Conclusion: Despite the improvement in perioperative management and cardiac surgery techniques, the perioperative mortality rate of VSR has remained high where the assist device is not accessible. We suggest VSR repair limited to certain centers with adequate experiences because of the low average annual number.

Background The coronavirus disease 2019 (COVID-19) pandemic has prompted the further virtualization of medical education. The satisfaction level of specific users such as cardiology residents with virtual education can augment its quality; hence, the significance of a valid and reliable questionnaire to obtain feedback is needed. This study aimed to design and measure validity and reliability of a satisfaction questionnaire for virtual education of cardiology residents during COVID-19 pandemic. Materials and methods In this cross-sectional study, a self-administered questionnaire was developed by the faculty members of Rajaie Cardiovascular Medical and Research Center. Reliability was tested utilizing Cronbach's alpha and intercorrelation which was tested using Pearson's correlation coefficient test (ICC). Factor analysis was done by the Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett's sphericity test. The statistical analyses were performed with the SPSS software version 22. Results The face validity index was determined via an assessment of the relevance, clarity, and simplicity of each item, and values >0.79 were accepted. The total Cronbach's alpha coefficient was calculated 0.93. Concerning test-retest reliability, the correlation between two rounds of evaluation was >80 (P > 0.001) and ICC was 0.99 (P = 0.001). The content validity evaluation yielded an index of 0.95 and a ratio of 0.91. The principal component factor analysis, conducted to investigate construct validity, generated four domains. Conclusions The study results confirmed the validity and reliability of the designed questionnaire to evaluate the level of satisfaction of cardiology residents with virtual learning in COVID-19 pandemic.

Endothelial injury and microvascular/macrovascular thrombosis are common pathophysiologic features of coronavirus disease-2019 (COVID-19). However, the optimal thromboprophylactic regimens remain unknown across the spectrum of illness severity of COVID-19. A variety of antithrombotic agents, doses and durations of therapy are being assessed in ongoing randomized controlled trials (RCTs) that focus on outpatients, hospitalized patients in medical wards, and critically-ill patients with COVID-19. This manuscript provides a perspective of the ongoing or completed RCTs related to antithrombotic strategies used in COVID-19, the opportunities and challenges for the clinical trial enterprise, and areas of existing knowledge, as well as data gaps that may motivate the design of future RCTs.