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Samah I Abohamr,1,2 Mohammad O Kattea,3 Rami M Abazid,4 Mubarak A Aldossari,2 Nayef Al Asiri,2 Ayman Uthman Alhussini,2 Khalid I Al Hussaini,5 Glowi A Alasiri,6 Asghar Ali,7 Eman Elsheikh1,8 1Department of Cardiology, College of Medicine, Tanta University Hospital, Tanta, Egypt; 2Chairman of cardiology services, Mouwasat medical group, Al-Khobar, Saudi Arabia; 3Nassau University Medical Center, East Meadow, NY, USA; 4Internal Medicine Department, Sault Area Hospital, Sault Ste Marie, Northern Ontario Medical School University (NOSM), Sault Ste Marie, Ontario, Canada; 5Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 4233-13317, Saudi Arabia; 6Department of Biochemistry, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 4233-13317, Saudi Arabia; 7Clinical Biochemistry Laboratory, Department of Biochemistry, School of Chemical and Life Sciences (SCLS), Jamia Hamdard, New Delhi, 110062, India; 8Internal Medicine Department, King Faisal University, Alahsa, Saudi ArabiaCorrespondence: Khalid I Al Hussaini, Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 4233-13317, Saudi Arabia, Email kialhussaini@imamu.edu.sa Asghar Ali, Clinical Biochemistry Laboratory, Department of Biochemistry, School of Chemical and Life Sciences (SCLS), Jamia Hamdard, New Delhi, 110062, India, Email asgharali@jamiahamdard.ac.inPurpose: COVID-19 is a new disease caused by the recently discovered SARS-CoV-2 virus. The COVID-19 disease manifests in several ways and it may affect various systems, including the gastrointestinal, musculoskeletal, neurological, cardiovascular, and pulmonary systems. Individuals who have ad-additional health conditions, such as cardiovascular disorders, are particularly more likely to experience illness and death. This study aimed to assess the clinical effect of COVID-19 on myocardial injury, as measured by troponin elevation, and to determine if this effect has an impact on the outcome.Patients and Methods: This retrospective study was conducted at King Saud Medical City. The electronic medical records used to identify all admitted patients between March 23 and June 15, 2020, with a laboratory-confirmed positive COVID-19 diagnosis who had troponin I measured.Results: During the study period, 768 COVID-19-positive patients were hospitalized. Of those, 187 patients were excluded because the troponin level was not measured. The remaining 581 (75.7%) had troponin I measured. Overall, 89 of 581 (15.3%) patients died. Of those, 67.8% were in the markedly elevated cTnI group, 8.5% were in the mildly elevated cTnI group, whereas no deaths were reported in the group with normal cTnI levels.Conclusion: Myocardial injury was observed in COVID-19-admitted patients at a significant level that warrants attention to this consequence. In older individuals with pre-existing cardiovascular comorbidities, the diagnosis of myocardial injury was linked to a higher likelihood of being admitted to the intensive care unit, experiencing a worse prognosis, and ultimately, death.Keywords: myocardial infarction, cardiovascular comorbidities, ARDS, biomarker, cytokine storm, risk stratification

Background: Although positron emission tomography (PET) imaging is well established for its diagnostic role in cardiac sarcoidosis, less is known about the prognostic value of PET and its use in risk stratification for major adverse cardiac events (MACE)., Objectives: The goal of this study was to perform a systematic review and meta-analysis looking at the prognostic value of PET imaging in patients with cardiac sarcoidosis., Methods: Study investigators systematically searched EMBASE (Excerpta Medica dataBASE), MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ClinicalTrials.gov, and the European Union Clinical Trial Registry for cardiac sarcoidosis and PET imaging. The primary outcome of interest was MACE., Results: The search revealed 3,010 records, of which 55 studies were included. This represented 5,250 patients. Factors associated with MACE included the following: the combination of abnormal fluorodeoxyglucose (FDG) uptake and perfusion defect, which had an OR of 2.86 (95% CI: 1.74-4.71; P < 0.0001); abnormal perfusion or FDG uptake, which had an OR of 2.69 (95% CI: 1.67-4.33); abnormal FDG uptake, which had an OR of 2.61 (95% CI: 1.51-4.50); focal abnormal right ventricular uptake, which had an OR of 6.27 (95% CI: 3.19-12.32; P < 0.00001); and a lack of response to immunosuppression on serial PET, which had an OR of 8.43 (95% CI: 3.25-21.85; P < 0.0001). A QUIPS (Quality in Prognostic Studies) tool analysis found a low to moderate risk of bias, particularly given the small sample sizes in the individual studies., Conclusions: Multiple cardiac PET parameters provide risk stratification value in cardiac sarcoidosis. Focal right ventricular uptake and a lack of response to immunosuppressive therapy on serial PET imaging were particularly predictive of MACE., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Patients with low HEART (History, Electrocardiogram, Age, Risk factors, and Troponin level) risk scores who are discharged from the emergency department (ED) may present clinical challenges and diagnostic dilemmas. The use of downstream non-invasive stress imaging (NISI) tests in this population remains uncertain. Therefore, this study aims to investigate the value of NISI in risk stratification and predicting cardiac events in patients with low-risk HEART scores (LRHSs)., Methods: We prospectively included 1384 patients with LRHSs between March 2019 and March 2021. All the patients underwent NISI (involving myocardial perfusion imaging/stress echocardiography). The primary endpoints included cardiac death, non-fatal myocardial infarction and unplanned coronary revascularisation. Secondary endpoints encompassed cardiovascular-related admissions or ED visits., Results: The mean patient age was 64±14 years, with 670 (48.4%) being women. During the 634±104 days of follow-up, 58 (4.2%) patients experienced 62 types of primary endpoints, while 60 (4.3%) developed secondary endpoints. Multivariable Cox models, adjusted for clinical and imaging variables, showed that diabetes (HR: 2.38; p=0.008), HEART score of 3 (HR: 1.32; p=0.01), history of coronary artery disease (HR: 2.75; p=0.003), ECG changes (HR: 5.11; p<0.0001) and abnormal NISI (HR: 16.4; p<0.0001) were primary endpoint predictors, while abnormal NISI was a predictor of secondary endpoints (HR: 3.05; p<0.0001)., Conclusions: NISI significantly predicted primary cardiac events and cardiovascular-related readmissions/ED visits in patients with LRHSs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The aim of this study is to analyze the diagnostic value of global longitudinal strain (GLS) in detecting inducible myocardial ischemia in patients with chest pain undergoing treadmill contrast-enhanced stress echocardiography (SE)., Methods: We retrospectively enrolled all patients who underwent invasive coronary angiography after treadmill contrast-enhanced SE. Rest and peak-stress myocardial GLS, segmental LS, and LS of 4-chamber (CH), 2-CH, and 3-CH views were reported. Luminal stenosis of more than 70% or fractional flow reserve (FFR) of < 0.8 was considered significant., Results: In total 33 patients were included in the final analysis, among whom sixteen patients (48.4%) had significant coronary artery stenosis. Averaged GLS, 3-CH, and 4-CH LS were significantly lower in patients with critical coronary artery stenosis compared to those without significant stenosis (-17.1 ± 7.1 vs. -24.2 ± 7.2, p = 0.041), (-18.2 ± 8.9 vs. -24.6 ± 8.2, p = 0.045) and (-14.8 ± 6.2 vs. -22.8 ± 7.8, p = 0.009), respectively. Receiver operating characteristic (ROC) analysis of ischemic and non-ischemic segments demonstrated that a cut-off value of -20% of stress LS had 71% sensitivity and 60% specificity for ruling out inducible myocardial ischemia (Area under the curve was AUC = 0.72, P < 0.0001)., Conclusion: Myocardial LS measured with treadmill contrast-enhanced stress echocardiography demonstrates potential value in identifying patients with inducible myocardial ischemia., (© 2024. The Author(s).)

Background: Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural-biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison with three-dimensional echocardiographic findings in patients with severe mitral regurgitation., Methods: We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber, 2-chamber, long-axis, and commissural views; CBA was performed by obtaining the bicommissural view and simultaneous biplane imaging of the medial, middle, and lateral MV aspects. The findings of both TEE approaches were compared with three-dimensional TEE data to assess the diagnostic accuracy of MPA and CBA., Results: The mean patient age was (65 ± 11) years, and 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% and 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% and 95%. The CBA and MPA were the least accurate in identifying the P3 scallop-88% and 82% respectively; however, both were the most accurate in assessing the A2 segment-95% and 97%, respectively. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. Three-dimensional TEE was found to have a strong agreement with CBA (averaged kappa of 0.81, P < .0001) and a modest agreement with MPA (averaged kappa of 0.61, P < .0001) in identifying abnormal anterior or posterior segments. On the other hand, three-dimensional TEE had a weak agreement with CBA (kappa of 0.43, P < .0001) and no agreement with MPA (kappa of 0.14, P = .153) in the assessment of commissural involvements., Conclusion: The CBA is more accurate than the MPA in the assessment of MV commissural involvement. Given the accuracy differences of the 2 approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallop assessments., (Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Respiratory infections are one of the most common comorbidities identified in hospitalized patients. The coronavirus disease 2019 (COVID-19) pandemic greatly impacted healthcare systems, including acute cardiac services., Aim: This study aimed to describe the echocardiographic findings of patients with COVID-19 infections and their correlations with inflammatory biomarkers, disease severity, and clinical outcomes., Methods: This observational study was conducted between June 2021 and July 2022. The analysis included all patients diagnosed with COVID-19 who had transthoracic echocardiographic (TTE) scans within 72 h of admission., Results: The enrolled patients had a mean age of 55.6 ± 14.7 years, and 66.1% were male. Of the 490 enrolled patients, 203 (41.4%) were admitted to the intensive care unit (ICU). Pre-ICU TTE findings showed significantly higher incidence right ventricular dysfunction (28 [13.8%] vs. 23 [8.0%]; P  = 0.04) and left ventricular (LV) regional wall motion abnormalities (55 [27.1%] vs. 29 [10.1%]; p  < 0.001) in ICU patients compared to non-ICU patients. In-hospital mortality was 11 (2.2%), all deaths of ICU patients. The most sensitive predictors of ICU admission ( p  < 0.05): cardiac troponin I level (area under the curve [AUC] = 0.733), followed by hs-CRP (AUC = 0.620), creatine kinase-MB (AUC = 0.617), D-dimer (AUC = 0.599), and lactate dehydrogenase (AUC = 0.567). Binary logistic regression showed that reduced LV ejection fraction (LVEF), elevated pulmonary artery systolic pressure, and dilated right ventricle were echocardiographic predictors of poor outcomes ( p  < 0.05)., Conclusion: Echocardiography is a valuable tool in assessing admitted patients with COVID-19. Lower LVEF, pulmonary hypertension, higher D-dimer, C-reactive protein, and B-type natriuretic peptide levels were predictors of poor outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Abohamr, Abazid, Alhumaid, Abdulrahim, Aldossari, Khedr, Werida, Alkheledan, Aleid, Abdelhamid, AI Mefarrej, Abdelhamid, Alaboud, Alhasan, Gomaa and Elsheikh.)

Three-Dimensional (3-D) echocardiography is becoming increasingly used to diagnose and describe the spatial location of valvular pathologies and atrial septal defects during transesophageal echocardiography (TEE). The role of 3D-TEE is not well established in diagnosing other congenital heart diseases like partial anomalous pulmonary venous drainage (PAPVD) and coronary anomalous. We propose a step by step approach to producing computed tomography-simulated axial images from 3-D TEE to simplify TEE interpretation and diagnosis of cardiac abnormalities., (© 2023 Wiley Periodicals LLC.)

Objectives: The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents., Design: Retrospective analysis., Setting: University Hospital, London, Ontario Canada ., Participants: Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled., Primary and Secondary Outcome Measures: Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of >5% reversible myocardial perfusion defect., Results: During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE ( p =  0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p  = 0.004 and p  = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p  = 0.062)., Conclusion: Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Abazid, Romsa, Warrington, Akincioglu, Akincioglu, Smettei, Bureau, Tzemos and Vezina.)

Objectives: To analyze the clinical and echocardiographic changes in individuals with morbid obesity who underwent bariatric surgery., Methods: In total, 59 obese patients with body mass index >35 kg/m 2 were prospectively enrolled. We assessed baseline pre-operative and a 6-month post-operative lipid profile, hemoglobin A1c, echocardiography, lifetime, and a 10-year risks of atherosclerotic disease for all patients., Results: The mean patients' age was 37±12 years, with 40 (67.8%) women. We found that the pre-operative total cholesterol (4.2±1.1 vs. 4.4±1.1, p =0.014) and triglyceride levels (1.4±0.7 vs. 1.8±0.8, p <0.0001) were significantly lower than post-operative levels, while post-operative high-density lipoprotein levels were significantly higher (1.5±0.5 vs. 1.2±0.3, p <0.0001). The calculated 10-year risk of atherosclerotic cardiovascular disease was significantly lower post-operatively (1.1±1.6% vs. 1.6±1.8%, p <0.0001). Echocardiography follow-up revealed that diastolic dysfunction was more prevalent pre-operatively than that post-operatively (41% vs. 10%, p <0.0001). Post-operative left ventricular (LV) mass was significantly lesser than the pre-operative mass (168±252 g vs. 187±255 g, p =0.019), whereas the post-operative LV diastolic (46.5±7 mm vs. 38.5±18 mm, p =0.002) and systolic dimensions (31±5 mm vs. 25±11 mm, p =0.001) were significantly smaller., Conclusion: Bariatric surgery resulted in a significant amelioration in lipid profile, reduction in LV mass, and LV cavity dimensions., (Copyright: © Saudi Medical Journal.)

A 61-year-old male presented with symptoms of decompensated heart failure and cardiogenic shock. Transthoracic and transesophageal echocardiography showed severely impaired left ventricular (LV) systolic function (LVEF of 20-25%), bicuspid aortic valve with moderate aortic insufficiency and no significant stenosis, dilated coronary sinus and a tortuous vascular structure in the left-sided atrioventricular groove. Cardiac computed tomography confirmed the diagnosis of persistent left superior vena cava and a giant coronary artery fistula to the coronary sinus. Cardiac magnetic resonance illustrated non-specific late gadolinium enhancement in the mid-wall of the septum. The patient was treated medically and with cardiac re-synchronization therapy., (© 2022 Wiley Periodicals LLC.)

Purpose: We present this case series exploring the complementary role of coronary computed tomography angiography (CCTA) to SPECT myocardial perfusion imaging (MPI) in the detection of myocardial necrosis., Methods: A cardiac hybrid imaging database search identified 144 patients with a previous history of ST-segment elevation myocardial infarction treated with coronary revascularization. CCTA and MPI scans were evaluated to determine whether CCTA had an added value to MPI in detecting myocardial necrosis., Results: Five patients with patent stents and/or bypass grafts and both fixed perfusion defects on MPI and sub-endocardial hypo-perfusion on CCTA were identified. The extent and location of the perfusion defects were closely correlated between the CCTA and SPECT MPI images., Conclusion: In this series, CCTA and SPECT MPI were found to play a complementary role in the assessment of fixed perfusion defect, with CCTA adding specificity to the diagnosis of myocardial necrosis., (© 2022. The Author(s).)

Purpose: 177 Lu-Dotatate is an emerging treatment modality for patients with unresectable or metastatic well-differentiated NETs. This study examines survival predictors in patients who received 177 Lu-Dotatate., Methods: A retrospective single-center review was conducted, examining 47 individuals with progressive well-differentiated NETs treated with 177 Lu-Dotatate (four induction cycles of 5.5 GBq at 10-week intervals followed by eight maintenance cycles of 3.7 GBq at 6-month intervals)., Results: Median follow-up was 63.1 months with a median progression-free survival (PFS) of 34.1 months. However, median overall survival (OS) was not reached at the time of analysis. The presence of ≥ 5 bone metastases (hazard ratio HR 4.33; p = 0.015), non-gastroenteropancreatic (non-GEP) NETs (HR 3.22; p = 0.025) and development of interim ascites (HR 3.15; p = 0.047) independently predicted a worse OS. Patients with chromogranin A of ≥ 4 × upper limit of normal (ULN) had shorter OS (p < 0.001) and PFS (p = 0.004). Similarly, those with pre-existing ascites demonstrated a worse OS (p = 0.009) and PFS (p = 0.026). Liver metastases involving greater than 50% liver volume and the existence of unusual metastatic locations had a negative impact on OS (p = 0.033) and PFS (p = 0.026), respectively., Conclusion: High burden of skeletal and hepatic metastases, non-GEP-NETs, chromogranin A of ≥ 4 × ULN, unusual metastatic sites, pre-existing and interim ascites are predictors of poor outcomes in patients treated with 177 Lu-Dotatate. These common indicators can be used for the risk stratification and identification of patients most likely to benefit from PRRT., Trial Registration: ClinicalTrials.gov identifier: NCT02236910, Retrospectively registered on September, 2014., (© 2021. The Author(s).)

Objectives: Accelerated atherosclerosis is a well-established phenomenon after coronary artery bypass grafting surgery (CABG). In this study, we analysed coronary artery calcium (CCS) progression after CABG., Methods: We retrospectively measured the CCS Agatston score (AS), volume score (VS) and mass score (MS) of 39 patients before and after CABG. The annualised CCS change and annualised CCS percent change of each coronary artery, coronary artery segments proximal and distal to anastomosis were analysed., Results: Mean age at the time of the surgery was 59.8±8.5 years. Follow-up period between the first and second CT scans was 6.7±2.8 (range, 1.1-12.8) years. Annualised CCS percent change (AS, VS and MS) of the coronary segments proximal-to-anastomosis did not differ from that of the non-grafted coronary arteries as follow: segments proximal-to-anastomosis: median (Q1-Q3) 12.8 (5.0-37.4), 13.7 (6.1-41.1) and 14.9 (5.4-53.7), left main coronary artery 12.6 (7.4-43.8), 22.0 (8.1-44.4) and 18.2 (7.3-57.4), non-grafted left circumflex artery: 13.5 (4.4-38.1), 10.5 (2.9-45.2) and 11.5 (7.1-47.9) and non-grafted right coronary artery: 31.4 (14.4-74.5), 25.2 (16.7-62.0) and 31.3 (23.8-85.6), respectively. Likewise, annualised percent change (AS, VS and MS) was similar between the native coronary arteries. Multivariate regression analysis showed that diabetes mellitus was the only predictor of annualised percent progression of the total CCS of >15% (HR, 8.12; 95% CI, 1.05 to 26.6; p=0.04)., Conclusion: The CCS post-CABG did not follow an accelerated progression process. Among coronary artery disease risk factors, diabetes mellitus is the only predictor of annualised CCS percent progression of >15% post-CABG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine the incidence and risk factors of delirium in the cardiac care unit (CCU) and intensive care unit (ICU)., Methods: This multicenter prospective observational study was conducted between July 2019 and November 2019 in the central region of Saudi Arabia. All patients admitted to the critical care units were enrolled, and their demographic data and risk factors of delirium were reported., Results: A total of 165 patients were included: 76 (46.1%) admitted to the CCU and 89 (53.9%) admitted to the ICU. The mean age was 55.1±18 years, and 45 (27.3%) were women. We found that 24/165 (14.5%) patients developed delirium during admission. Importantly, variables significantly associated with delirium group were female gender: (24.5% versus 10.8%, p =0.028), malnutrition (29.2% versus 5%, p <0.001), the presence of urinary catheter (75% versus 30.5%, p =0.001), septicemia (50% versus 14.9%, p <0.001), intubation (41.7% versus 10.6%, p =0.001), low hemoglobin (10.79±2.91 versus 12.05±2.77, p =048), and prolonged prothrombin time (PT) (15.87±5.17 versus 13.60±3.28, p =0.011)., Conclusion: The incidence of delirium was 14.5% among patients admitted to critical care units in the central region of Saudi Arabia. Septicemia, prolonged PT, malnutrition, and urinary catheter are significant predictors of delirium., (Copyright: © Saudi Medical Journal.)

Background: The aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery., Methods: We reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH., Results: We found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4-9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2-64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10-8.43), P=0.033., Conclusions: RA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2557). RMA, JGR, BK and WCV report other from Lawson Research Institute, London, Ontario, Canada, during the conduct of the study. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Competing Interests: Author Relationship With Industry This work was supported by the Lawson Research Institute, London, Ontario, Canada. Dr. Kiaii has been a consultant for Medtronic, Edward LifeSciences, Boston Scientific, and Johnson & Johnson. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objectives: To provide a detailed study of demographic, baseline comorbidities, clinical features, and outcome for Coronavirus disease 2019 (COVID-19) patients., Methods: A record-based case-series study conducted from March 23 to June 15, 2020 in King Saud Medical City, Riyadh, Saudi Arabia. Demographic data, clinical presentation, laboratory investigations, complications, and in-hospital outcome of COVID-19 patients collected with analysis of the clinical characteristics for survivors and deceased., Results: A total of 768 patients were included. The mean age was 46.36±13.7 years and 76.7% were men. Approximately 96.3% reported more than one comorbidity; diabetes mellitus was the most frequent (46.4%). Fever (84.5%), cough (82.3%), and shortness of breath (79.8%) were the main presenting symptoms. During the follow-up, pneumonia reported in 68.6%, acute respiratory distress syndrome in 32.7%, septic shock in 20.7%, respiratory failure in 20.3%, and acute kidney injury in 19.3%. Approximately 45.8% of enrolled patients required intensive care unit admission. Lung disease (odd ratio [OR]=3.862 with 95% confident interval [CI] (2.455-6.074), obesity (OR=3.732, CI=2.511-5.546), smoking (OR=2.991, CI=2.072-4.317), chronic kidney disease (OR=2.296. CI=1.497-3.521), and diabetes mellitus (OR=2.291, CI=1.714-3.063) are predictors of ICU admission. Fatality ratio was 4.27%; therefore, men were more prevalent in dead group., Conclusion: Coronavirus disease 2019 places a huge burden on healthcare facilities, particularly in patients with comorbidity. Coronavirus disease 2019 patients who are obese and smokers with history of diabetes mellitus have a high risk of death.

Introduction: The objective of this study was to evaluate the safety and feasibility of the immediate return of patients with ST-elevation myocardial infarction (STEMI) to their originating hospitals after primary percutaneous coronary intervention (PPCI)., Methods: This was a prospective study, conducted between January 2014 and December 2017. All patients with STEMI who were transferred for PPCI and returned back to their referring hospitals (RB group) were included and compared to the onsite STEMI population (OS group). Patient's demographics, PPCI data, bleeding and adverse cardiovascular events (ACEs) occurring during transfer, hospital stay, and at 1-month follow-up were recorded., Results: A total of 156 patients in the OS group were compared against 350 patients in the RB group. We found that first medical contact to balloon time and onset of symptoms to balloon time were significantly longer in the RB group than in the OS group [110 ± 67 min vs. 46 ± 35 min ( p < 0.0001) and 366 ± 300 min vs. 312 ± 120 min ( p = 0.04)], respectively. There were no differences between the RB and OS groups in in-hospital ACEs: 0.3% versus 0% ( p = 0.8) for death, 0.3% versus 0.6% ( p = 0.79) for reinfarction, 0.6% versus 2% ( p = 0.72) for bleeding, and no reported cases of repeat revascularization; and 30-day ACEs: 0.3% versus 0.6% ( p = 0.82) for death, 0.3% versus 1.2% ( p = 0.68) for reinfarction, 0.6% versus 2% ( p = 0.74) for bleeding, and 1.1% versus 1.2% ( p = 0.9) for repeat revascularization., Conclusion: The immediate return of patients with noncomplicated STEMI after PPCI to their referring hospitals is safe and feasible, and can be used as part of an effective reperfusion strategy., Competing Interests: The authors declare that they have no conflicts of interest., (© 2020 Saudi Heart Association.)

Objective: Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients., Materials and Methods: We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients' demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients' medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period., Results: In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively)., Conclusion: Patient-physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs., (Copyright: © 2019 Avicenna Journal of Medicine.)

Objectives: To analyze predictors of death in elderly patients diagnosed with acute coronary syndrome (ACS). Methods: A record-based study carried out between January 2016 and January 2018 at The central province in Saudi Arabia. All elderly patients (greater than 75 years) with definite diagnosis of ACS were retrospectively included. Demographic data, echocardiographic, and angiographic parameters were reported.  Results: A total of 179 patients were enrolled, 129 (72%) were male. The mean age was 79±4.7 years. Approximately 102 (57%) patients were diagnosed with ST-segment elevation myocardial infarction (STEMI). Of all 125 (70%) underwent invasive coronary angiography, we found that 43 (24%) had significant single vessel disease (1VD), 29 (16.2%) had 2 vessel disease (2VD), and 41 (22.9%) had 3 vessel disease (3VD) or left main stenosis. During hospitalization 21 (11.7%) patients died, t-test analysis showed patients who died were significantly older (82±6.7 versus [vs.] 79±4.2 years, p=0.003). In addition  we found that ejection fraction was lower in death group (30.2%±10.7) vs. (36.5%±1.1) in survivors, p=0.017); STEMI  was more common in death group (90.5%) vs. (52.5%) in survivors, p=0.001); similarly,  the  prevalence of 3VD was higher  in death group (38.1%) vs. (20.9%) in survivors, p=0.018). Importantly, PCI was not significantly different between death and survival groups (40% vs. 53.8%, p=0.177). A multivariate regression analysis demonstrated that predictors of death were: age (hazard ratio [HR], 1.214; 95% confidence interval [CI], 1.122-1.384; p less than 0.0001), intubation (HR, 10.106; 95% CI, 9.844-10.792; p less than 0.0001), and raised creatinine kinase-MB (CK-MB) (HR, 1.005; 95% CI, 1.002-1.013; p=0.04) predicted in hospital death.  Conclusion: Older age, mechanical ventilation and raised CK-MB can significantly predict death in elderly patients (greater than 75-year-old) diagnosed with ACS; nevertheless, PCI showed no survival benefits.

Background: Coronary computed tomography angiography (CCTA) is commonly used to diagnose coronary artery diseases (CADs). We aimed to determine the utility of CCTA among patients suspected with CAD at the Prince Sultan Cardiac Center Qassim., Materials and Methods: CCTA results of 425 cardiac patients, complaining of chest pain with suspected CAD, were used to classify coronary artery stenosis into two types: obstructive if the luminal stenosis was ≥50% or nonobstructive if it was <50%. Follow-ups were conducted through clinic or phone-based interviews to document any of the following endpoints: nonfatal myocardial infarctions (MIs) or cardiac deaths (CDs), representing the major cardiac events. All other cardiac cases, including hospitalization with unstable angina, and/or late coronary revascularization, were documented., Results: Patients with a normal coronary artery were 278 (65.5%). The number of patients with nonobstructive and obstructive diseases was 85 (20%) and 62 (14.5%), respectively. After 19.6 ± 7 months of follow-up, 21 cardiac events occurred in twenty patients: five major adverse events (two CDs and three nonfatal MIs), ten hospitalizations due to unstable angina, and six late coronary revascularizations. Furthermore, the cumulative all-cardiac-event rates in patients with normal coronary arteries, nonobstructive CAD, and obstructive CAD were 3 (1%), 7 (8.2%), and 11 (17.7%), respectively. However, patients with normal CCTA had no major cardiac events during the follow-up., Conclusion: CCTA can provide valuable prognostic information on patients with suspected CAD. Patients are likely to have excellent intermediate outcomes if the coronary arteries are confirmed to be normal by CCTA., Competing Interests: There are no conflicts of interest.

Introduction: Image noise can negatively affect the overall quality of coronary computed tomography angiography (CCTA)., Objectives: The purpose of this study was to evaluate the relationship between image noise and fat volumes in the chest wall. We also aimed to compare these with other patient-specific predictors of image noise, such as body weight (BW) and body mass index (BMI)., Methods: We undertook a cross-sectional, single-center study. A tube voltage of 100 kV was used for patients with BW <85 kg and 120 kV for BW ≥85 kg. The image noise in the aortic root, single-slice fat volume (SFV) at the level of the left main coronary artery and the total fat volume of the chest (TFV) were analyzed., Results: A total of 132 consecutive patients were enrolled (mean age ± standard deviation, 51 ± 11 years; 64% male). The mean image noise was 30.5 ± 11 Hounsfield units (HU). We found that patients with image noise >30 HU had significantly higher SFV (75 ± 33 vs. 51 ± 24, p  < 0.0001) and TFV (2206 ± 927 vs. 1815 ± 737, p  < 0.01) compared with patients having noise ≤30 HU, whereas BW and BMI showed no significant difference (78 ± 13 vs. 81 ± 14, p  < 0.34) and (28.7 ± 4.7 vs. 26.8 ± 3.8, p  < 0.19), respectively. Linear regression analysis showed that image noise has better correlation with SFV ( R  = 0.399; p  < 0.0001); and TFV ( R  = 0, p  < 0.009) than BMI ( R  = 0.154, p  < 0.039) and BW ( R  = -0.102, p  = 0.12)., Conclusions: Fat volume measurements of the chest wall can predict CCTA image noise better than other patient-specific predictors, such as BW and BMI.

Objectives: To assess the perception and awareness of cardiologists in Saudi Arabia about medical fitness to drive in different cardiovascular diseases. Methods: The study is a cross-sectional survey-based study between June 2018 and July 2018. Cardiologists were asked to complete a self-administered questionnaire inquiring about awareness of driving fitness and educating patients regarding driving risks in specific cardiovascular conditions. Results: A total of 194 cardiologists completed the study survey; there were 30.4% consultants, 59.3% specialists, and 10.3% residents. Out of 195, 72% were aware of the existence of particular international driving regulations for cardiovascular diseases, whereas 28% were not aware. Although, no Saudi guidelines assessing fitness-to-drive are available, 11% of the participants claimed awareness of such regulations. Interestingly, we found that cardiologists had never or rarely educated their patients regarding the potential risks of driving: 49% in symptomatic angina, 47% when ejection fraction is ≤35%, 39% in symptomatic valvular diseases, 26% after cardioverter defibrillators implantation, and 23% after non-elective percutaneous coronary interventions. Conclusion: There is a lack of awareness among cardiologists in Saudi Arabia about international guidelines regarding medical driving fitness. This study highlights the necessity of formulating appropriate national driving regulations for cardiovascular diseases.

Background: Coronary computed tomography angiography (CCTA) is increasingly being used for the evaluation of coronary artery disease; however, radiation exposure remains a major limitation of its use., Objective: To compare image quality and radiation exposure in two groups of patients undergoing CCTA using a 256-slice dual-source helical computed tomography scanner with high-pitch (FLASH) or prospective [step-and-shoot (SAS)] gating protocols., Methods: A prospective, single-center study was performed in our cardiac center. In total, 162 patients underwent CCTA with either FLASH or SAS scanning protocols. Subjective image quality was graded on the basis of a four-point grading system (1, non-diagnostic; 2, adequate; 3, good; 4, excellent). Objective image quality was assessed using image signal, noise, and signal-to-noise ratio (SNR). The effective radiation dose was also estimated., Results: The clinical and demographic characteristics of the patients in both groups were similar. The median age of the patients in both groups was 48.43 years, and males accounted for 63% and 68.7% of the FLASH and SAS groups, respectively. We found that the subjective image quality obtained with the FLASH protocol was superior to that obtained with the SAS protocol (3.35 ± 0.6 mSv vs. 2.82 ± 0.61 mSv; p  < 0.001). Image noise was higher in the FLASH group but was not statistically significant (25.0 ± 6.13 vs. 24.0 ± 6.8; p  = 0.10), whereas the signal and SNR was significantly higher with the FLASH protocol than with the SAS protocol [(469 ± 116 vs. 397 ± 106; p  > 0.001) and (21.6 ± 8.7 mSv vs. 16.6 ± 7.7 mSv; p  < 0.001), respectively]. Radiation exposure was 62% lower in the FLASH protocol than in the SAS protocol, (1.9 ± 0.4 mSv vs. 5.12 ± 1.8 mSv; p  < 0.001)., Conclusion: The use of 256-slice CCTA performed with the FLASH protocol has a better objective and subjective image quality as well as lower radiation exposure when compared with the use of prospective electrocardiography gating.

Objectives: To investigate the effect of Ramadan fasting on the symptoms of chronic heart failure with a reduced ejection fraction (HFrEF). Globally, more than one billion Muslims fast during Ramadan. Data regarding the effect of fasting in heart failure patients with a reduced ejection fraction are limited., Methods: We prospectively studied 249 outpatients with HFrEF who undertook Ramadan fasting at tertiary care cardiac center in Saudi Arabia in 2017. We obtained information regarding the clinical assessment, diagnosis, emergency department visits, and hospitalization during and in the month preceding Ramadan., Results: We enrolled 249 patients, 227 (91%) undertook the fast for the entire month. During Ramadan, 209 (92%) patients remained hemodynamically stable, whereas 18 (8%) developed instability. The mean New York Heart Association (NYHA) functional class was significantly lower in the stable than in the unstable group (1.46±0.7 vs. 3.22±0.55, p less than 0.0001), although no intergroup differences were observed before Ramadan. Patients from the unstable vs. the stable group showed significantly less adherence to medications (67% vs. 94%, p less than 0.0001) and to diet (39% vs. 79%, p less than 0.0001), and a lower likelihood of demonstrating ischemic cardiomyopathy as an underlying etiology of HFrEF (33% vs. 57%, p=0.046). Dependent t-test analysis including all patients showed that the NYHA classification before Ramadan was significantly higher than during Ramadan (2.19±0.9 vs. 1.6±0.8, t-value 8.5, p less than 0.0001)., Conclusion: In most patients with chronic HFrEF, Ramadan fasting is considered safe. Non-adherence to medication and diet are significantly associated with decompensated heart failure during Ramadan.

Introduction: The aim of this study is to compare three different echocardiographic methods commonly used in the assessment of left ventricle (LV) ejection fraction (EF)., Methods: All patients underwent full echocardiography including LVEF assessed using M-mode, automated EF (Auto-EF), and visual estimation by two readers., Results: We enrolled 268 patients. Auto-EF measurement was feasible in 240 (89.5%) patients. The averaged LVEF was (52% ± 12) with the visual assessment, (51% ± 11) with Auto-EF and (57% ± 13) with M-mode. Using Bland-Altman analysis, we found that the difference between the mean visual and the Auto-EF was not significant (-0.3% [-0.5803-0.0053], P = 0.054). However, the mean EF was significantly different when comparing visual versus M-mode and Auto-EF versus M-mode with the mean differences: (-2.4365 [-2.9946--1.8783], P < 0.0001) and (-2.1490 [-2.7348--1.5631], P < 0.0001) respectively. Inter-observer variability analysis of the visual EF assessment between the two readers showed that intraclass correlation coefficient was 0.953, (95% confidence interval: 0.939-0.965, P < 0.0001), with excellent correlation between the two readers: R = 0.911, P < 0.0001)., Conclusion: The two-dimensional echocardiographic methods using Biplane Auto-EF or visual assessment were significantly comparable, whereas M-mode results in an overestimation of the LVEF., Competing Interests: There are no conflicts of interest.

Purpose: Graftability of the left anterior descending artery (LAD) has important prognostic value for coronary artery bypass graft (CABG) surgery. However, with a chronic total occlusion (CTO) of the LAD, invasive coronary angiography (ICA) may be insufficient to determine its graftability. We evaluated the role of coronary computed tomographic angiography (CTA) in the assessment of CTO and LAD graftability when the distal vessel segment was incompletely visualized by ICA., Materials and Methods: We enrolled 31 patients with equivocal eligibility for CABG due to CTO of the LAD with poor distal flow defined by ICA. Patients with LAD diameters ≥1.5 mm by CTA underwent CABG surgery, and the vessel diameter was reassessed intraoperatively., Results: The mean age was 54±14 years. Seven patients (23%) had suitable LAD targets on CTA and underwent successful CABG. Another 24 patients (77%) had nongraftable LADs. Patients with a graftable LAD showed no significant difference between mean LAD diameter measured by CTA and during surgery (1.6±0.3 vs. 1.5±0.3 mm, P=0.21). The preoperative left ventricular ejection fraction was not significantly different between groups (35%±8% vs. 35%±7%, P=0.2). However, after a mean follow-up of 21±7 months, left ventricular ejection fraction was significantly higher in vascularized patients (41%±5.8% vs. 34%±8%, P=0.01, respectively). Six of 7 patients had patent LAD grafts on CTA at 1-year follow-up., Conclusion: CTA may provide valuable information about chronically occluded LAD size and graftability when ICA is inconclusive.

Purpose: Excessive quantity of epicardial adipose tissue (EAT) is considered a risk factor for coronary artery disease (CAD). There are limited data, however, on the relationship between the quality of EAT and CAD. We investigated the association between the density and volume of EAT and subclinical CAD defined by positive coronary artery calcification (CAC), using computed tomography (CT)., Materials and Methods: We reviewed 609 consecutive CT scans of patients with a mild to moderate risk for CAD to assess the EAT volume, which was measured manually by tracing the parietal pericardial sac on axial images. Fat density was recorded in mean Hounsfield units (HU), and CAC was measured using the Agatston method., Results: The mean patients' age was 50±11 years, and 393 (64.5%) were men. Overall, CAC was present in 135 (22%) patients, of whom 97 (72%) were men and 38 (28%) were women. The mean EAT volume and density were 65±27 cm and -87.0±3.4 HU, respectively. Patients with CAC had significantly higher EAT volume (74±27 vs. 62±26 cm, P<0.001) and lower EAT density (-88±3 vs. -87±3.4 HU, P<0.001) compared with patients without CAC. Multivariate regression analysis showed that both EAT density (hazard ratio, 0.879; 95% confidence interval, 0.817-0.946; P=0.001) and EAT volume >100 cm (hazard ratio, 1.693; 95% confidence interval, 1.256-2.999; P=0.029) predicted the presence of CAC., Conclusions: Both the quality and quantity of EAT derived from noncontrast CT scan predict subclinical CAD, with lower density and higher volume of epicardial fat associated with higher CACs.

Background: Coronary artery anomalies (CAAs) affect about 1% of the general population based on invasive coronary angiography (ICA) data, computed tomography angiography (CTA) enables better visualization of the origin, course, relation to the adjacent structures, and termination of CAAs compared to ICA., Objective: The aim of our work is to estimate the frequency of CAAs in Qassim province among patients underwent cardiac CTA at Prince Sultan Cardiac Center., Methods: Retrospective analysis of the CTA data of 2235 patients between 2009 and 2015., Results: The prevalence of CAAs in our study was 1.029%. Among the 2235 patients, 241 (10.78%) had CAAs or coronary variants, 198 (8.85%) had myocardial bridging, 34 (1.52%) had a variable location of the Coronary Ostia, Twenty two (0.98%) had a separate origin of left anterior descending (LAD) and left circumflex coronary (LCX) arteries, ten (0.447%) had a separate origin of the RCA and the Conus artery. Seventeen (0.76%) had an anomalous origin of the coronaries. Six (0.268%) had a coronary artery fistula, which is connected mainly to the right heart chambers, one of these fistulas was complicated by acute myocardial infarction., Conclusions: The incidence of CAAs in our patient population was similar to the former studies, CTA is an excellent tool for diagnosis and guiding the management of the CAAs.

Background: Excessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis., Methods: We performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS., Results: In 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p  = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p  = 0.001; 92 ± 207 vs. 337 ± 157, p  = 0.001; and 79 ± 158 vs. 256 ± 142, p  = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis., Conclusions: CCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.