Mohammad Reza Movahed,1,21. Department of Medicine, University of Arizona Sarver Heart Center, Tucson, AZ12. Department of Medicine, University of Arizona, Phoenix, Phoenix, AZ 2Correspondence to:Mohammad Reza Movahed, MD, PhDClinical Professor of MedicineUniversity of Arizona Sarver Heat Center1501 North Campbell AvenueTucson, AZ 85710Email: rmova@aol.comTel: 949 400 0091Key words:Chronic total occlusion; percutaneous coronary intervention; angioplasty; CTO; stenting; stent, coronary artery disease, atherosclerosis; interventionConflict of interest: None,

INTRODUCTION:Advanced chronic kidney disease is described as stages 3-5 of the chronic kidney disease classification defined as a reduction in glomerular filtration rate of less than 60 ml/min (1). Chronic kidney disease (CKD) has been known as one of the prominent risk factors for coronary artery disease (2). Percutaneous coronary intervention (PCI) has become an acceptable alternative to open heart surgery in patients suffering from coronary artery disease (3). This procedure improves patient survival, appropriately controls angina symptoms, reduces the need for long-term hospitalization, and reduces treatment costs (4-5). However, similar to other invasive or even minimally invasive therapeutic interventions, this procedure should be performed in high-risk groups with some considerations and precautions. These patients may experience far different outcomes than low-risk patients who have PCI. In patients with chronic kidney disorders, the need to use contrast material, scheduling consecutive dialysis sessions, the risk of microembolization, and requiring arterial wall instrumentation may lead to poorer outcomes of the PCI procedure, and the clinical benefits of PCI may be lower in such patients (6). In the last decade, various trials have evaluated the outcomes of the procedure in patients with CKD, which were basically associated with contradictory results. In a large, randomized trial (ISCHEMIA-CKD) on 777 CKD patients who underwent PCI procedure or medical therapy, 3.2-year outcomes including death, cardiac ischemic attack, or re-hospitalization were shown to be similar in both groups (7). In several trials, the presence of underlying chronic kidney disease was considered a major risk factor for long-term poorer outcomes following PCI, such as higher mortality and progression of renal impairment (8-9), also the impaired renal elimination of antithrombotic drugs exposes these patients to a higher likelihood of bleeding complications (10-11). During our literature review on databases, we found a small number of studies looking into the impacts of PCI on ACKD patients, Limpijankit and his colleague as one of the few studies in this matter determined one-year survival of PCI among 207 CKD patients stage 4-5 without dialysis and 5 with dialysis was 65.2%, 68.0% and 69.4 respectively (12).   Therefore, the outcome of PCI procedures in patients with ACKD still remains uncertain. In the present study, we investigated the clinical outcomes of PCI in cases with Advanced chronic kidney disease and compared the in-patient mortality rate of PCI between ACKD and non-ACKD candidates.

Background: The prevalence of hypertrophic cardiomyopathy (HCM) can be silent and can present with sudden death as the first manifestation of this disease. The goal of this study was to evaluate any association between reported physical symptoms with the presence of suspected HCM. Method: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 4,120 subjects between the ages of 6 and 79 underwent echocardiographic screening. We evaluated any association between any symptoms and suspected HCM defined as any left ventricular wall thickness ≥ 15 mm. Results: The total prevalence of suspected HCM in the entire study population was 1.1%. The presence of physical symptoms were not associated with HCM (chest pain in 4.3% of participant with HCM vs. 9.9% of the control, p=0.19, palpitation in 4.3% of participant with HCM vs. 7.3% of the control., p=0.41, shortness of breath in 6.4% of participant with HCM vs. 11.7% of the control., p=0.26, lightheadedness in 4.3% of participant with HCM vs. 13.1% of the control., p=0.07, ankle swelling in 2.1% of participant with HCM vs. 4.0% of the control., p=0.52, dizziness in 8.5% of participant with HCM vs. 12.2% of the control., p=0.44). Conclusion: Echocardiographic presence of suspected HCM is not associated with a higher prevalence of physical symptoms in the participants undergoing screening echocardiography. This finding confirmed that HCM can be asymptomatic in many patients and a questionnaire cannot distinguish the HCM population from a control group.

Subtitle: A word of caution in the use of Impella in patients with cardiogenic shockAuthor: Mohammad Reza Movahed, MD, PhD 1,2,3University of Arizona Tucson1 University of Arizona Phoenix2Correspondent:M Reza Movahed, MD, PhD, FACP, FACC, FSCAI, FCCPClinical Professor of Medicine, University of Arizona, TucsonClinical Professor of Medicine, University of Arizona, Phoenix1501 No Campbell AvenTucson, AZ 85724Tel: 949 400 0091Email: rmova@aol.comConflict of interest: NoneKeywords: Acute coronary syndrome; cardiogenic shock; shock; cardiac assist device; IABP; cardiac support; congestive heart failure; device use; myocardial infarction; ImpellaWith great interest, I read the manuscript entitled “Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device (MCS)  vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock” in JAMA Cardiology. (1) They found that the adjusted 30-day mortality risk post-PCI was 41.3% in the IABP cohort which was 11.4% lower than with the use of MCS and was similar to no device et al (difference IABP vs no device 3.1%). Their findings were consistent even though they adjusted for every possible confounding factor.    They also avoided acceptance that mortality was much lower in the IABP cohort in comparison to MCS and was similar to any device use despite the fact that most patients treated with IABP are much sicker and if IABP had no positive effect on mortality, higher mortality suggesting a positive effect of IABP on mortality in their patients with cardiogenic shock.  We published a preprint paper (2) pending peer review publication by analyzing over 844,020 patients with all types of cardiogenic shocks using the largest available Nationwide Inpatient Sample (NIS) database. 101,870 were treated with IABP and 39,645 with an Impella. Consistent with their results, we found much higher inpatient mortality rates with Impella use despite adjusting for over 47 confounding factors. Regardless of the severity or any underlying condition, Impella increased mortality in patients with acute myocardial infarction-induced cardiogenic shock (AMICS) by approximately 30% whereas IABP reduced mortality by over 30%  regardless of severity or hospital type. The benefit of IABP was also consistent regardless of comorbidities and also was highly significant in comparison to no device in all subgroup cohorts. Two meta-analyses of Impella trials showed worse outcomes using Impella in patients with AMICS. (3,4) Finally, using the NIS database, patients with AMICS showed significantly higher mortality. (5)  Until large randomized trials are conducted, cardiologists need to exert utmost caution in the judiciary use of Impella and utilize it only in selected patients until more safety data are available..

1. IntroductionMany authors (1) using unjustified Medina Coronary bifurcation lesion classification that unfortunately divides true bifurcation lesions into three unnecessary groups: 111, 101, and 011 as opposed to The Movahed classification summarizing true bifurcation lesions into one simple category called B2 lesions.

Author: Mohammad Reza Movahed, MD, PhD, FACP, FCCP, FACC, FSCAI1,2,3University of Arizona Tucson1 University of Arizona Phoenix2Correspondent:M Reza Movahed, MD, PhD, FACP, FACC, FSCAI, FCCPClinical Professor of Medicine, University of Arizona, TucsonClinical Professor of Medicine, University of Arizona, Phoenix1501 No Campbell AvenTucson, AZ 85724Tel: 949 400 0091Email: rmova@aol.comConflict of interest: NoneKeywords: Acute coronary syndrome; Wellen EKG; Inverted U waves; anterior myocardial infarction; proximal left anterior ascending artery; acute myocardial infarctionWith great interest, I read the paper about challenges in Electrocardiography entitled “Inverted U Waves—Red Flags in Electrocardiogram” by Shu et al. (1)  Initially, the authors correctly described Wellen’s syndrome (2) that was seen in their patient’s first  EKG consistent with proximal LAD disease. However, they described the second EKG as an Inverted U wave syndrome with reference to Dr. Gerson who described first time this condition. Unfortunately, the authors did not review EKGs that were published under inverted U waves in the literature including original Dr. Gerson’s papers. By reviewing published EKGs under inverted U wave including the referenced Dr. Gerson publication, it can clearly be seen that the so-called inverted U wave is actually a terminally inverted T wave similar to Wellen’s description of Wellen’s EKG as inverted U wave. (3,4) Figures below are showing the original EKG illustration described by Dr. Gerson as inverted U wave syndrome.  The first EKG is from the paper describing an inverted U wave after exercise and the second EKG is from the subsequent paper describing an inverted U wave at rest as a warning sign for proximal LAD lesions:

Short title: Respiratory Maneuvers during Invasive Cardiac ProceduresMehrbod Vakhshoori MD1, Mohammad Reza Movahed MD, PhD 1,2University of Arizona Sarver Heart Center, Tucson, Arizona1University of Arizona, College of Medicine, Phoenix, Arizona2

Classic Wellen’s syndrome or by some authors described as inverted U waves is consistent of biphasic terminal T waves inversion usually seen in V2 and V3 leads highly predictive of high grade left main (LM) or proximal left anterior ascending artery (LAD) disease. In this case, we are reporting a case of minimal terminal T wave changes not large enough to qualify as Wellen’s EKG but similar to classic Wellen was associated with high grade LM and LAD disease despite negative troponins.

There has always been a question about what transmits electromagnetic waves and/or gravitational forces. Furthermore, the nature of dark matter and dark energy remains elusive. This paper is introducing a new simple theory that may explain many unexplained phenomena in physics. This theory should stimulate many physicists and mathematicians for a new way of thinking about our universe and unsolved mysteries in physics. In this theory, the presence of new particles in the universe called "Spacetime or Gravilon (Gravi for gravity and L for light and on for transmission)", are proposed as the replacement for the space time fabric / field described by Einstein. The fact that gravity and light have the same speed for their propagation can be explained by the presence of Spacetime particles as they utilize the same vehicle (Spacetime particles) for their effect. The presence of Spacetime particles in the universe may explain the unknown phenomena called dark matter. The maximal possible contraction of time particles between space particles can explain why light or any matter cannot surpass the maximal speed of light and why time nearly stops with the light speed. These particles are simplified in this paper but are most likely complicated structures that could have more dimensions than the known four dimensional space time and could be very diverse in nature with multiple subunits than simple illustration in this paper. However, in the core, these particles are made from two fundamental parts. One part contains space particles connected to each other via other part time particles. Time particles could have particle quality but could also be pure energy. Basically, these Gravilon particles introduced in this paper have two major components. One is space and the other one is time. Space particles connected to the time particles could explain Spacetime effect known in the relativity theory. The main difference between this theory and the Einstein relativity, is the fact that this theory is introducing Spacetime particles instead of Space-time fabric. Connection of space with time particles can also explain relativity. Furthermore, interaction of these particles with matter can give matters their masses as an explanation for why matter has mass. Higgs bosons and fields could be also a part of Spacetime particles. This simple theory could also explain limitations of light speed and why light and gravity have the same speed for their effect. Furthermore, probably the distance between Spacetime particles can be stretched or contracted to fit small propagating particles in between based on their sizes. However, these stretching, and contraction properties should have limits. Those particles that can fit between the Spacetime particles before reaching the maximal stretching capability of Spacetime particles will behave mostly as quanta following quantum mechanics rules. Once propagating particles are too

SARS-CoV2 virus, COVID-19, was first reported in Wuhan, China in 2019. The most common symptoms of COVID-19 are dry cough, fever, and diarrhea that occur within 2-14 days of exposure. Primary infection from COVID-19 develops in the respiratory tract. Cardiovascular disease has become a more prominent manifestation of COVID-19 infection however very little is known regarding the impact of COVID-19 on the cardiac conduction system. We present a young patient with COVID-19 who developed a permanent third-degree Atrioventricular (AV) heart block. This report is the first documentation of COVID-19 induced permanent third-degree heart block in a young male.

Objective There are some suggestions that global myocardial strain (GLS) early after ST-elevation myocardial infarction (STEMI) is a predictor of improvement in left ventricular ejection fraction (LVEF) after myocardial infarction. The goal of this study was to evaluate predictive value of GLS in patient with STEMI. Methods The study population consists of 43 patients with acute STEMI and no history of prior coronary intervention treated with primary percutaneous coronary intervention. LVEF and myocardial strain indices were measured 48hours and two months after STEMI by transthoracic echocardiography and speckle tracking method. More than 5% improvement in LV EF was considered significant improvement. Results GLS values were significantly higher in patients with >5% improvement in LVEF 2 months after the STEMI (GLS=15.76% in patients with >5% improvement vs. 11.54% in the other group,P <0.05). ROC analysis suggested GLS values more than 13.5 to be a predictor of significant LVEF improvement 2 month after STEMI. Higher GLS was observed in patients with inferior, posterior and inferoseptal STEMI versus anterior, extensive or anteroseptal STEMI and in patients with right coronary occlusion versus occlusion of the left anterior descending or circumflex arteries. Conclusion We have observed that early longitudinal LV strain after STEMI is a predictor of during first 2 months after STEMI. This is a useful method to predict early LV recovery after STEMI. GLS values more than 13.5%is a significant predictor of significant LVEF improvement.