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1.  Atrioventricular block as the initial presentation of calcified bicuspid aortic valve 
ARYA Atherosclerosis  2014;10(1):59-64.
Bicuspid aortic valve (BAV) is one of the most common and important congenital heart disorders in adults. If a patient with congenital disorders is not diagnosed early, the patient’s disease may progress to a severe condition and thus diagnosis of the main disorder will be rendered difficult.
A 34 year-old male patient referred to a referral medical care unit for cardiac electrophysiological study with cardiac shock due to complete heart block 3 months ago and he underwent Dual-Chamber permanent pacemaker (PPM) implantation. Thick and calcified bicuspid AV with invasion to interventricular septum, moderate to severe valve insufficiency (AI), severe aortic valve stenosis (AS), and dilated ascending aorta were observed at his echocardiography. Aortic valve replacement (AVR), aneurysm of ascending aorta, root replacement with tube graft (Bentall Procedure), and also a 3 chambers intracardiac defibrillator (ICD) were used. After 2 weeks of operation, he was discharged and at the first post-hospitalization visit (1 week later), his cardiovascular condition was acceptable.
Thick calcified aortic root is a less studied and potential contributing risk factor for AV block after AVR. Therefore, in candidates of aortic valve replacement, considering conductive disorders, especially in patients with calcified valve, is mandatory. Irreversible AV block requiring PPM implantation is a rare condition following AVR.
PMCID: PMC4063517  PMID: 24963316
Atrioventricular Block; Bicuspid Aortic Valve; Calcified Valve
2.  Safety of herbal medicine in treatment of weight loss 
ARYA Atherosclerosis  2014;10(1):55-58.
Obesity is a common health problem in both developed and developing countries. There are many unconventional therapies, including herbal medicine, to treat this condition. Some people believe that herbal medicines are safe. This case and review is about adverse complication of treating obesity with some herbal medicine.
A 19 year old male with sever obesity (120 kg) used green tea (15 cups of green tea per day) and an intensive dietary regimen to lose weight. He lost 30 kg after 2 months. At that time, one day after usual exercise he suddenly lost consciousness due to left ventricular fibrillation.
Use of herbal medicine for weight reduction is not always safe. Moreover, for some herbal medicine the risk is sufficient to shift the risk-benefit balance against the use that medicine.
PMCID: PMC4063522  PMID: 24963315
Herbal Medicine; Sudden Death; Complication; Obesity
3.  A rare anomalous origin of left subclavian artery from the circle of Willis in combination with right sided aortic arch: A case report 
ARYA Atherosclerosis  2013;9(5):303-305.
One of the rare aortic congenital abnormalities is right sided aortic arch which is occurred in approximately 0.1% of the population. The anomalous origin of the subclavian arteries has also been reported.
In this study, a case of a right-sided aortic arch with anomalous left subclavian artery origin from the cerebral arteries is presented which was diagnosed in Computed tomography angiogram (CT angiogram) and angiography of a 10-year-old boy referred due to recurrent chest pains during two weeks before admission and pulselessness of his left upper limb and left carotid artery.
Many of the congenital vascular anomalies may have no obvious signs or symptoms and therefore the exact history and physical examination could help us in better diagnosis. Besides, some of these anomalies are associated with other abnormalities of other body organs particularly the cardiac system.
PMCID: PMC3845692  PMID: 24302940
Congenital Anomaly; Great Arteries; Pediatric
4.  Aortic valve streptococcus group B endocarditis post-extracorporeal shock wave lithotripsy 
ARYA Atherosclerosis  2013;9(5):300-302.
Sub-acute left-sided bacterial endocarditis is a serious condition that may present with variable clinical manifestations. Its symptoms include both sterile and infected emboli, and various immunological phenomena.
This report presents a 55 year old man with frequency and dysuria after a lithotripsy and several admissions with urosepsis. Due to the suspicion of infective endocarditis echocardiography was done which confirmed streptococcus group B endocarditis.
Streptococci group B is one of the rare causes of infective endocarditis, but it was observed after various producers such as lithotripsy.
PMCID: PMC3845697  PMID: 24302939
Group B Streptococci; Infective Endocarditis; Lithotripsy
5.  Global coronary arteries spasm in a young patient 
ARYA Atherosclerosis  2013;9(4):260-262.
Coronary artery spasm is a transient narrowing of coronary arteries that slows or stops blood flow through the artery.
We present a 42-year-smoker man without any medical problem who developed syncope. Coronary angiography revealed diffuse significant narrowing of proximal left anterior descending artery (LAD), 90% osteal stenosis of large obtuse marginal (OM), 90% diffuse narrowing of proximal right coronary artery (RCA), which was relieved by intracoronary administration of nitrate. He was discharged on calcium channel blockers and nitrates but one month later developed syncope again and died.
Multivessel coronary artery spasm should be considered in young smoker patients without any other coronary risk factors who present with syncope.
PMCID: PMC3746942  PMID: 23970922
Syncope; Implantable Cardiac Defibrillators; Variant Angina
6.  A case report of truncus arteriosus communis and genetic counseling 
ARYA Atherosclerosis  2013;9(4):254-259.
Truncus arteriosus communis (TAC) is a rare heart disorder with the prevalence of approximately 1%, mostly in male newborns. In this disease, aorta and pulmonary artery have not been separated during fetus development and both originate jointly from left ventricle. In addition, various disorders are reported like ventricular septal defect (VSD), mitral and tricuspid valves defects, aortic septal defect (ASD), reduction of lung and lung vessels’ resistance, pulmonary hypertension, increase in heart rate, high perspiration, bad digestion, and tetralogy of Fallot.
Parents of deceased patient were referred for genetic counseling after the death of third girl due to severe cardiac disorder. Cardiologist declared the disease in deceased girl as TAC based on findings along with VSD, ASD and hypoplastic aortic arch which resulted to death in the first day of birth.
There was no chromosomal disorder in chromosome analysis of patient’ skin. Parents were interested to have another child, so they were referred to university's Genetic Counseling Center to become aware of their next child’s condition. This disorder is genetically heterogeneous and multifactorial and because all external factors are not recognized, the accurate estimation of risk is not possible and the probability of risk for the next child is about 10% to 20%.
PMCID: PMC3746948  PMID: 23970921
Heart Disorder; Truncus Arteriosus Communis; Genetic Counseling
7.  Five chambered heart or large atrial appendage aneurysm: A report of two cases 
ARYA Atherosclerosis  2013;9(3):213-215.
Isolated intrapericardial LAA aneurysm is a rare cardiac anomaly which manifests with angina, dyspnea on exertion (DOE), systemic embolization, arrhythmia, and congestive heart failure.
A 30-year-old female and a 46-year-old male were referred for evaluation of abnormal cardiac contour on chest radiograph and echocardiographic findings and non-specific symptoms. Transesophageal echocardiography suggested left atrial appendage (LAA) mass filled with clots. The mass had no compression on cardiac chambers and global ejection fraction was within normal limits. The intraoperative diagnosis was isolated congenital LAA aneurysm. After confirmation of the diagnosis, it was resected. She was discharged with uneventful postoperative course. At follow-up she was asymptomatic.
These cases demonstrate the role of on-time surgical approaches in the prevention of fatal complication of this rare cardiac anomaly.
PMCID: PMC3681275  PMID: 23766780
Left Atrial Appendage; Aneurysm; Clot
8.  Traumatic right pericardial laceration with tension pneumopericardium associated with hemodynamic instability: A case report 
ARYA Atherosclerosis  2013;9(3):210-212.
Pneumopericardium is a rare complication following thoracic trauma, and urgent treatment is rendered necessary when it causes tension pneumopericardium due to cardiac tamponade.
The case presented here is a right pericardial laceration with tension pneumopericardium due to falling from a height, presenting to the emergency clinic of our hospital with hemodynamic instability.
Pneumopericardium that might develop due to blunt thoracic trauma can easily be diagnosed, may result in cardiac tamponade, and is a potentially fatal pathology without treatment.
PMCID: PMC3681283  PMID: 23766779
Pneumopericardium; Trauma; Cardiac Tamponade; Fall
9.  Percutaneous coronary intervention of an obstructive left anterior descending artery with anomalous origin of right coronary artery 
ARYA Atherosclerosis  2013;9(2):164-166.
Coronary artery anomalies are a rare type of congenital anomalies with an incidence of 1.3% during routine cardiac catheterization. Anomalous origin of the coronary arteries is considered an incidental finding without clinical significance. This case describes a patient in whom evaluation of chest pain revealed an obstructive left anterior descending artery as well as an anomalous right coronary artery arising from the left coronary sinus. The patient underwent successful percutaneous coronary intervention of the left anterior descending artery and was discharged home free of angina 3 days later.
PMCID: PMC3653244  PMID: 23690818
Anomalous Right Coronary Artery; Obstructive Left Anterior Descending Artery; Percutaneous Coronary Intervention
10.  Dabigatran, a direct thrombin inhibitor, can be a life-saving treatment in heparin-induced thrombocytopenia 
ARYA Atherosclerosis  2013;9(1):112-114.
Several studies have emphasized thrombosis associated with thrombocytopenia as a potentially fatal complication of heparin. A number of agents are used for this condition. As a new oral, reversible direct thrombin inhibitor, dabigatran has been approved for short-term thromboprophylaxis after elective hip and knee replacement surgery. We present a case of dabigatran administration in a patient with femoral fracture.
A 67-year-old woman referred to the orthopedic ward of Shariati Hospital (Isfahan, Iran) due to femoral fracture following an accident. Immediately after surgery, she was found to be suffering from deep vein thrombosis (DVT) in her lower extremity despite sufficient prophylaxis by enoxaparin. Laboratory data showed severe thrombocytopenia. Considering the clinical history, an initial diagnosis of heparin-induced thrombocytopenia was made. Doppler ultrasound confirmed the diagnosis. Heparin was thus replaced with dabigatran which increased platelet count to the normal range and improved DVT.
Dabigatran can be a life-saving treatment in heparin-induced thrombocytopenia. However, it is contraindicated in patients with renal dysfunction since it may cause potentially catastrophic results.
PMCID: PMC3653267  PMID: 23690810
Heparin Induced Thrombocytopenia; Heparin; Enoxaparin; Dabigatran
11.  Sinus of Valsalva aneurysm: An uncommon presentation 
ARYA Atherosclerosis  2012;8(3):164-166.
Sinus of Valsalva aneurysm (SVA) may be congenital or acquired. They could mimic ventricular tumor symptoms and cause signs and symptoms of ventricular outflow tract obstruction. They may also involve the conduction system and cause palpitations or syncopal episodes. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) serve as quick, noninvasive methods to provide information on size and location of aneurysmal dilatation and cardiac chamber involvement. These methods can identify any associated anomalies or complications. This study presents a patient with unruptured SVA.
A 46-year-old man, who had been suffering from nonspecific symptoms such as exercise intolerance and weakness for a few months, referred to our clinic in Isfahan (Iran). In TTE, a large mass was observed in the right ventricle. SVA was suspected after meticulous probing. This diagnosis was confirmed by TEE and computed tomography angiography. At open heart surgery, an SVA with a lot of clots it was removed.
SVA must be kept in mind when a tumor-like mass is observed in the right ventricle. Detailed evaluation would thus be necessary to rule out SVA and to prevent wrong diagnosis and treatment that can sometimes be catastrophic.
PMCID: PMC3557003  PMID: 23358699
Sinus Valsalva; Aneurysm; Cardiac Tumor
12.  Diagnostic dilemma: Saccular aneurysm or pseudoaneurysm of the ascending aorta with dissection above level of leaflets 
ARYA Atherosclerosis  2012;8(3):167-169.
In true aneurysm, the wall of aneurysm is composed of the normal histological components of aorta. A false aneurysm (pseudoaneurysm) represents a rupture which does not contain the normal histological components of aorta. It is a fibrous peel that has formed from a small perforation of aorta. We describe an unusual presentation that has signs which some of them are only manifested in true aneurysm and some others only in pseudoaneurysm.
An 85-year-old man underwent elective coronary angiography for chest pain work-up. Our evaluation by invasive angiography and CT angiography showed aortic dissection. In surgery we found that dissection flap was composed of some parts of intima and media layers. These signs leaded to confusing symptoms. Localized bulging of ascending aorta had continued to brachiocephalic artery (transverse arch involvement). Dissection flap was composed of some part of intima and media layers. It was a strange case, it was not solely a perivascular hematoma and it did not have all three layers of aorta wall. Partial aorta replacement was performed. The operation and recovery was uneventful.
This unusual presentation of disease has not been mentioned in literatures. Our experience can help to manage similar cases. This case was the first unusual presentation of its type.
PMCID: PMC3557002  PMID: 23358558
Saccular Aneurysm; Aortic Dissection; Pseudoaneurysm; Aneurysm
13.  Anomalous Origin of the Left Coronary Artery from the Right Sinus of Valsalva and Sever Mitral Stenosis 
ARYA Atherosclerosis  2011;6(4):149-152.
Congenital coronary anomalies are presented in approximately1% of patient referred for cardiac catheterization. Among the congenital coronary anomalies, a separated anomalous origin of all the coronary arteries from the right sinus of valsalva is very uncommon. We report a rare occurance of simultaneous occurence of mitral stenosis with ectopic origin of left main stem coronary artery from right sinus of Valsalva.
PMCID: PMC3347829  PMID: 22577434
Anomalous Origin of Coronary Arteries; Mitral Stenosis.
14.  Retained Jailed Wire: A Case Report and Literature Review 
ARYA Atherosclerosis  2011;7(3):129-131.
Side branch wiring is not infrequently used to protect side branch flow after main vessel stenting. Rarely, it becomes difficult to retrieve the jailed wire behind the stent and therefore it may even be detached and remained in the circulation. This article presents a report of such a case and reviews treatment options.
PMCID: PMC3347859  PMID: 22577460
Jailed wire; Stent; Retrieval
15.  A case report on holt-oram syndrome (heart-hand) 
ARYA Atherosclerosis  2011;7(2):87-92.
The Holt-Oram Syndrome (HOS) or the Heart-Hand syndrome is considered as an overt autosomal hereditary disease with a complete influential effect and variable expression that emerges due to a genetic mutation. It can be vividly characterized by heart disorders and deficiencies in hand structure. Despite the existing genetic heterogeneity, the variable integration between HOS and the T-BX5 gene from the T-BOX Gene Complex has been observed during which various mutations have been reported in the affected patients. The T-BOX Gene Complex is located on chromosome 12 (12 q 24.1), and is able to encode a copying factor. That has a conservative motive with 180 amino acids. The deficiencies in only 1/3 of patients have been observed caused by the mutation of this gene.
This case was a 10-year-old child with hand disorders, incomplete growth of clavicle, moving problems in elbow joint and shoulder, disorder in ventricle and auricle walls. The disease was diagnosed as HOS, based on clinical examination and drawing the family tree diagram. It was impossible to investigate molecular mutation due to inaccessibility to the patient.
By investigating the family members and their deficiencies and imaging disorder variables according to different reports as well as parents’ state of health, the HOS can be defined as an overt heredity resulting from a new mutation in the germinating layer of sexual cells in one of the parents. There is a weak possibility that the disease results from a mosaic mutation in the male parent's testicle or the female parent's ovum. In this case, the probability for the disease to be repeated in parents’ next children will be guessed between 1 and 50%.
PMCID: PMC3347849  PMID: 22577452
Holt-Oram Syndrome; Hand- Heart Syndrome; T-BOX.
16.  Percutaneous transvenous mitral commissurotomy in a patient with situs inversus and dextrocardia: a case report 
ARYA Atherosclerosis  2011;7(1):47-50.
Dextrocardia situs inversus refers to the heart being a mirror image situated on the right side of the body. Distorted cardiac anatomy provides technical difficulties during fluoroscopy-guided transcatheter procedures. This is even more difficult in the case with percutaneous transvenous mitral commissurotomy (PTMC). Mitral valvuloplasty is a minimally invasive therapeutic procedure to correct an uncomplicated mitral stenosis by dilating the valve using a balloon. Here, we describe a case of a 25 years-old male with situs inversus and dextrocardia.
A 25 years-old man, having situs inversus and suffering from mitral stenosis was referred to hospital for PTMC. His initial examination findings were unremarkable and an electrocardiographic (ECG), trans-esophageal and transthoracic echocardiographic evaluation were performed. Mitral valve (MV) was dome shape and severely stenotic with mild mitral regurgitation (MR). Left ventricularejection Fraction (LVEF) was about 40%, Femoral arterial and venous punctures were made on the left side; the left femoral artery and vein were cannulated with a 5F arterial and 6F venous sheaths, respectively. Then special maneuvers were done to solve the mitral valve stenosis. At the end of the procedure, no MR was documented by checking LV angiogram and there were no signs of mitral stenosis (MS).
Mirror-image dextrocardia, as in our case, has been estimated to occur with a prevalence of 1:10,000. However, there are only a few case reports in the literature on PTMC in similar settings. This might be due to the fact that many of these patients undergo surgical commissurotomy due to the technical difficulties involved in a percutaneous procedure in general. Trans-septal catheterization is considered a technical challenge in anatomically malpositioned hearts, as it is fraught with a higher risk of cardiac perforation. Despite the challenging anatomy, PTMC has been demonstrated to be a safe and feasible option for MS in patients with unusual cardiac anatomy.
PMCID: PMC3347841  PMID: 22577444
PTMC; Dextrocardia; Surgical Commissurotomy
17.  Rare Occurrence of Simultaneous Dissection, Perforation and Thrombosis of External Iliac Artery Following Diagnostic Coronary Angiography: A Case Report 
ARYA Atherosclerosis  2010;6(2):82-84.
Lower extremity complications are the most common problems encountered during transfemoral diagnostic coronary artery angiography. Dissection, thrombosis and perforation of arteries of lower extremities although not uncommon, very rarely occur simultaneously. We did not find any report in the literature in this issue. In this report we describe a case of simultaneous occurrence of all three complications during coronary angiography in one patient. It also represents some of our uncertainties regarding the best management of the patient. In this patient, arterial perforation and dissection was managed conservatively, but we applied an invasive treatment (surgical thrombectomy) for arterial thrombosis with excellent short and long-term results.
PMCID: PMC3347813  PMID: 22577420
Perforation; Dissection; Thrombosis; External iliac artery; Acute arterial occlusion

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