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Background: Diabetes mellitus is one of the leading causes of vascular disease. The caseload is expected to reach 350 million by the year 2030, and it is estimated that up to 30% of patients are undiagnosed. Objective: The aim of the study was to explore the prevalence of prediabetes in patients admitted with acute coronary syndromes (ACS) who were not known to have diabetes and to determine the impact of prediabetes on in-hospital clinical outcomes versus non-diabetic patients. Patients and methods: This prospective study was conducted on 60 patients with acute coronary syndrome who were admitted to the intensive care unit (ICU), Internal Medicine Department, Faculty of Medicine, Zagazig University during the period from September 2019 to March 2020. All studied subjects were subjected to full history taking complete clinical examination, complete blood count, glycosylated haemoglobin (HbA1c), lipid profile, serum creatinine and oral glucose tolerance test (OGTT), ECG and ECHO. Results: There was a statistical significant difference between the studied groups regarding acute coronary syndrome types, glycated haemoglobin (HbA1c), serum creatinine, and high-density lipoproteins cholesterol. There was statistically significant difference between the studied patients grouped according to the clinical outcome regarding ACS types. Conclusion: Prediabetes is common in patients presenting with acute coronary syndrome who are not previously known to have diabetes. Pre-diabetic patients had worse in-hospital clinical outcomes compared with patients without diabetes. Pre-diabetic patients with ACS have greater prevalence of cardio-metabolic risk factors (abdominal obesity, and hypertension) as compared to non-diabetic patients. [ABSTRACT FROM AUTHOR]

Background: Prediabetes is common in patients presenting with ACS who are not previously known to have diabetes. Prediabetic patients had worse in-hospital clinical outcomes compared with patients without diabetes. The aim of the study was to explore the relation prediabetes patients with acute coronary syndromes the inhospital clinical outcomes. Patients and Methods: This prospective study was conducted on 60 patients with acute coronary syndrome who admitted to the intensive care unit (ICU), Internal Medicine Department, Faculty of Medicine, Zagazig University during the period from September 2019 to March 2020. All studied subjects were subjected to Full history taking Complete clinical examination, Complete blood count, Glycosylated haemoglobin (HbA1c), Lipid profile, Serum creatinine and Oral glucose tolerance test (OGTT), ECG and ECHO. Results: There was a statistical significant difference between the studied groups regarding acute coronary syndrome types, glycated haemoglobin (HbA1c), serum creatinine, and high-density lipoproteins. cholesterol. There was statistically significant difference between the studied patients grouped according to the clinical outcome regarding ACS types. Conclusion: Pre-diabetic patients had worse in-hospital clinical outcomes compared with patients without diabetes. Pre-diabetic patients with ACS have greater prevalence of cardiometabolic risk factors (abdominal obesity, and hypertension) as compared to non-diabetic patient. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Coronary complications are still the main reason for early mortality after an arterial switch operation. The high incidence of coronary anomalies in patients with transposition of the great arteries may increase the difficulty of coronary transfer, and among them, an intramural pattern was shown to be an independent risk factor of early mortality. However, recently published studies have reported that this rare coronary variant has no impact on the survival rate. The aim of this study was to assess the frequency of intramural coronary patterns in patients with transposition and the impact on overall mortality after an arterial switch operation. Additionally, we presented all coronary arrangements associated with intramural patterns in our cohort and the surgical techniques used to manage them successfully. METHODS All arterial switch operations were retrospectively reviewed. In each case, the surgical reports contained detailed graphical representations and coronary anatomy patterns. All operatively confirmed intramural patterns were included in the analysis. RESULTS Among 806 patients, 271 patients had coronary anomalies (33.62%), and 28 patients had an intramural pattern (3.47%), which was frequently associated with other complex coronary anomalies (P  < 0.001). Overall survival was significantly higher in patients with intramural coronary artery patterns than in those with other coronary variants (21.34% vs 8.74%, P  = 0.024, log-rank test). CONCLUSIONS Intramural patterns associated with transposition remain a surgical challenge and increase overall mortality in our cohort. To reliably confirm or reject the significance of the observed impact of this rare coronary variant, a multicentre data analysis is required. [ABSTRACT FROM AUTHOR]

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

Coronary complications in patients with transposition of the great arteries (TGA) after an arterial switch operation (ASO) are relatively rare, but of all the possible postoperative adverse events, they are potentially the most dangerous. The fate of the coronary arteries, which are transplanted during the neonatal ASO, remains uncertain. There is also no consensus regarding their postoperative evaluation, especially in asymptomatic patients. The aim of this study was to present the early results of routinely performed coronary computed tomography angiography (CCTA) in asymptomatic adolescents and young adults with TGA after an ASO. An initial series of 50 CCTAs performed in asymptomatic patients with TGA after an ASO were evaluated. In each case, a detailed examination of the coronary anatomy, its relationship to the surrounding structures, its exact position in the neoaortic sinus, and the presence of significant coronary abnormalities was performed. The CT scans revealed significant coronary abnormalities in 12 asymptomatic patients: three had acute proximal angulation and stenosis, four had an intra-arterial course, seven had a muscular bridge, one had a left anterior descending artery with an intramuscular course, and one had coronary fistulas to the pulmonary arteries. Additionally, in 25 patients, proximal acute angulation of at least one coronary artery was detected, and four of them had a high ellipticity index. Most of the potentially severe anatomical features were related to the left coronary artery or the left anterior descending artery. CCTA routinely performed on asymptomatic patients with TGA after an ASO provides accurate and useful information for postoperative management. The frequency of coronary anomalies and potentially dangerous anatomical features in this group of patients is high, and their impact on postoperative follow-up remains unknown. [ABSTRACT FROM AUTHOR]

Background: We present our clinical experience with coronary artery bypass grafting (CABG) in children.Methods: Ten children who underwent CABG between July 1995 and August 2017 were retrospectively analyzed. Data including congenital cardiac malformations, previous surgical procedures, age and sex, type of coronary complications, ischemic events preceding surgery, and ventricular function before and after CABG were recorded.Results: The study population consisted of five males and five females with a median age of 2.5 years (range, 88 days to 15 years). Eight internal mammary arteries (IMAs) and two saphenous veins were used for grafting. Indications for bypass grafting were coronary artery (CA) complications related to the post-arterial switch operation in six, CA complications during the Ross procedure in two, and an iatrogenic CA injury during complete repair of tetralogy of Fallot with abnormal CA, crossing the right ventricular outflow tract in two patients. Six of the grafts were performed as rescue procedures. Three patients died during hospitalization. The mean follow-up time was 6.8 years (range, 3 months to 18 years). Anastomoses were evaluated by coronary angiography in four patients, and were all patent. Echocardiography revealed normal myocardial function in all patients.Conclusion: Our study suggests that the IMA should be the graft of choice in children due to its growth potential and long-term patency. [ABSTRACT FROM AUTHOR]

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

Background: The incidence and short- and long-term outcomes of coronary artery perforation (CAP) are not well described., Methods and results: We analyzed the characteristics and the short- and long-term outcomes of CAP among 243,149 patients undergoing percutaneous coronary interventions (PCI) from 2005 until 2017 in the national Swedish registry. We identified 1,008 cases of CAP with an incidence of 0.42%. Major adverse event rates were significantly higher in patients with CAP than non-CAP (P<0.001). The 1-year mortality rate was 16% vs. 5.5%, respectively, and the 12-year mortality rate was 52% vs. 34%. The restenosis rate was 5.2% vs. 3.1% and 17% vs. 9%, respectively. The target lesion revascularization rate was 4.2% vs. 2.6% and 10.5% vs. 7%. The stent thrombosis rate was numerically higher, 1.5% vs. 0.8% and 4.5 vs. 2.8%, with no stent thrombosis cases for equine pericardial stent grafts. Among the patients with tamponade a large proportion of cases occurred at the late stage (215/1,008, 21%), and most were not recognized in the cath-lab (167/215, 78%). The mortality rate for late tamponade was similar in patients suffering acute tamponade at 1 year (25.6% vs. 27%) or at 12 years (54% vs. 58%)., Conclusions: CAP is associated with an early high excess in morbidity and mortality but with low risk of additional adverse events in the long term. Late tamponade is as deadly as acute tamponade.

Introduction: Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential "red flags" revealed by other examinations., Patients and Methods: A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy., Results: Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results., Conclusion: Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.

An increased risk of cardiovascular death in Cytomegalovirus (CMV)-infected individuals remains unexplained, although it might partly result from the fact that CMV infection is closely associated with the accumulation of CD28 null T-cells, in particular CD28 null CD4 T-cells. These cells can directly damage endothelium and precipitate cardiovascular events. However, the current paradigm holds that the accumulation of CD28 null T-cells is a normal consequence of aging, whereas the link between these T-cell populations and CMV infection is explained by the increased prevalence of this infection in older people. Resolving whether CMV infection or aging triggers CD28 null T-cell expansions is of critical importance because, unlike aging, CMV infection can be treated. Methods: We used multi-color flow-cytometry, antigen-specific activation assays, and HLA-typing to dissect the contributions of CMV infection and aging to the accumulation of CD28 null CD4 and CD8 T-cells in CMV+ and CMV- individuals aged 19 to 94 years. Linear/logistic regression was used to test the effect of sex, age, CMV infection, and HLA-type on CD28 null T-cell frequencies. Results: The median frequencies of CD28 null CD4 T-cells and CD28 null CD8 T-cells were >12-fold (p=0.000) but only approximately 2-fold higher (p=0.000), respectively, in CMV+ (n=136) compared with CMV- individuals (n=106). The effect of CMV infection on these T-cell subsets was confirmed by linear regression. Unexpectedly, aging contributed only marginally to an increase in CD28 null T-cell frequencies, and only in CMV+ individuals. Interestingly, the presence of HLA-DRB1*0301 led to an approximately 9-fold reduction of the risk of having CD28 null CD4 T-cell expansions (OR=0.108, p=0.003). Over 75% of CMV-reactive CD4 T-cells were CD28 null . Conclusion: CMV infection and HLA type are major risk factors for CD28 null CD4 T-cell-associated cardiovascular pathology. Increased numbers of CD28 null CD8 T-cells are also associated with CMV infection, but to a lesser extent. Aging, however, makes only a negligible contribution to the expansion of these T-cell subsets, and only in the presence of CMV infection. Our results open up new avenues for risk assessment, prevention, and treatment., Competing Interests: Competing Interests: FK holds a part-time position as Head of Immunology (R&D) at JPT Peptide Technologies, Berlin, Germany. FK and RB partly own a patent describing the use of protein-spanning peptide libraries for the antigen-specific stimulation of T-cells as described in the present work (WO 01/63286 A2). AP, SC, FA, PB, GM, NT, HES, CR, BR, JRM, MV, MH and KAD have nothing to disclose.

Background: Kawasaki disease (KD) is a rare vasculitis seen predominantly in children. In developing countries, it is the leading cause of childhood-acquired heart disease. Besides a case report from 1981 there have been no data published dealing with the epidemiology and clinical aspects of KD in Austria., Methods: The purpose of the present study was to investigate the clinical spectrum of KD in a geographically determined cohort of infants, children, and adolescents that were diagnosed and treated at the University Hospital of Innsbruck from 2003-2012., Results: Thirty-two patients were included in the study with a median age of 32.96 months (2-192). 59.4% of the patients were aged between six months and four years. The male-to-female ratio was 1:1.13. Clinical examination revealed non-purulent conjunctivitis and exanthema as the most common symptoms (84.4%). 75% showed oropharyngeal changes, 21.9% had gastrointestinal complaints such as diarrhoe, stomachache or vomiting prior to diagnosis. One third of the patients were admitted with a preliminary diagnosis, whereas 78.1% were pre-treated with antibiotics. The median fever duration at the time of presentation was estimated with 4.96 days (1-14), at time of diagnosis 6.76 days (3-15).75% were diagnosed with complete KD, and 25% with an incomplete form of the disease. There was no significant difference in the duration of fever neither between complete and incomplete KD, nor between the different age groups. Typical laboratory findings included increased C-reactive protein (CRP) (80.6%) and erythrocyte sedimentation rate (ESR) (96%),leukocytosis (48.4%) and thrombocytosis (40.6%) without any significant quantitative difference between complete and incomplete KD. Coronary complications could be observed in six patients: one with a coronary aneurysm and five with tubular dilatation of the coronary arteries. Our patient cohort represents the age distribution as described in literature and emphasizes that KD could affect persons of any age. The frequency of occurrence of the clinical symptoms differs from previous reports - in our study, we predominantly observed non-purulent conjunctivitis and exanthema., Conclusion: KD should always be considered as a differential diagnosis in a child with fever of unknown origin, as treatment can significantly decrease the frequency of coronary complications.