Understanding the pattern and severity of myocarditis caused by the coronavirus disease 2019 (COVID‐19) vaccine is imperative for improving the care of the patients, and cardiac evaluation by MRI plays a key role in this regard. Our systematic review and meta‐analysis aimed to summarize cardiac MRI findings in COVID‐19 vaccine‐related myocarditis. We performed a comprehensive systematic review of literature in PubMed, Scopus, and Google Scholar databases using key terms covering COVID‐19 vaccine, myocarditis, and cardiac MRI. Individual‐level patient data (IPD) and aggregated‐level data (AD) studies were pooled through a two‐stage analysis method. For this purpose, all IPD were first gathered into a single data set and reduced to AD, and then this AD (from IPD studies) was pooled with existing AD (from the AD studies) using fixed/random effect models. I 2 was used to assess the degree of heterogeneity, and the prespecified level of statistical significance ( P value for heterogeneity) was <0.1. Based on meta‐analysis of 102 studies ( n = 468 patients), 79% (95% confidence interval [CI]: 54%–97%) of patients fulfilled Lake Louise criteria (LLC) for diagnosis of myocarditis. Cardiac MRI abnormalities included elevated T2 in 72% (95% CI: 50%–90%), myocardial late gadolinium enhancement (LGE) in 93% (95% CI: 83%–99%; nearly all with a subepicardial and/or midwall pattern), impaired left ventricular ejection fraction (LVEF) (<50%) in 4% (95% CI: 1.0%–9.0%). Moreover, elevated T1 and extracellular volume fraction (ECV) (>30), reported only by some IPD studies, were detected in 74.5% (76/102) and 32% (16/50) of patients, respectively. In conclusion, our findings may suggest that over two‐thirds of patients with clinically suspected myocarditis following COVID‐19 vaccination meet the LLC. COVID‐19 vaccine‐associated myocarditis may show a similar pattern compared to other acute myocarditis entities. Notably, preserved LVEF is probably a common finding in these patients. Evidence Level 4 Technical Efficacy Stage 3

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Background: Currently, no pharmacological or device-based intervention has been fully proven to reverse the no-reflow phenomenon. Objectives: To assess the efficacy and safety of intracoronary (IC) epinephrine in the management of no-reflow phenomenon following percutaneous coronary intervention (PCI), either as first-line treatment or after the failure of conventional agents. Design: Systematic review. Data sources and methods: PubMed and Scopus databases were systematically searched up to 28 May 2022, with additional manual search on the Google Scholar and review of the reference lists of the relevant studies to identify all published studies. Cohort studies, case series, and interventional studies written in English which evaluated the efficacy and safety of IC epinephrine in patients with no-flow phenomenon were included in our review. Results: Six of the 646 articles identified in the initial search met our inclusion criteria. IC epinephrine was used either as a first-line treatment [two randomized clinical trials (RCTs)] or after the failure of conventional agents (two cohort studies and two case series) for restoring the coronary flow, mainly after primary PCI. As first-line therapy, IC epinephrine successfully restored coronary flow in over 90% of patients in both RCTs, which significantly outperformed IC adenosine (78%) but lagged behind combination of verapamil and tirofiban (100%) in this regard. In the refractory no-flow phenomenon, successful reperfusion [thrombolysis in myocardial infarction (TIMI) flow grade = 3] was achieved in three out of four patients after the administration of IC epinephrine based on the results from both case series. Their findings were confirmed by a recent cohort study that further compared IC epinephrine with IC adenosine and found significant differences between them in terms of efficacy [% TIMI flow grade 3: (69.1% versus 52.7%, respectively; p value = 0.04)] and 1-year major adverse cardiac event (MACE) outcomes (11.3% versus 26.7%, respectively; p value ⩽ 0.01). Overall, malignant ventricular arrhythmias were reported in none of the patients treated with IC epinephrine. Conclusion: Results from available evidence suggest that IC epinephrine might be an effective and safe agent in managing the no-reflow phenomenon.

BackgroundCombined immune deficiencies (CIDs) with associated or syndromic features are a highly heterogeneous subgroup of inherited immune disorders. These patients represent specific clinical complications with an increased risk of autoimmune conditions.MethodsWe analyzed data of monogenic patients with syndromic CIDs adopted from the Iranian inborn errors of immunity registry up to January 2022. A comprehensive comparison in terms of demographic, clinical, and immunological features was performed between patients with and without autoimmunity and also among four mutation groups with the most registered cases including ATM, STAT3 (AD-LOF), DNMT3B/ZBTB24, and WAS mutations.ResultsA total of 137 patients with monogenic syndromic CIDs were included. Most commonly mutated genes were the ATM [80 (58.4%)] and STAT3 (AD-LOF) [19 (13.9%)], followed by DNMT3B [11 (8%)], and WAS [11 (8%)]. More than 18% of all patients with syndromic CIDs, including most DNMT3B/ZBTB24 mutations patients, were clinically diagnosed with antibody deficiencies before genetic evaluation. Patients with ATM and WAS mutations had the latest age of onset and the lowest age of diagnosis, respectively. Autoimmune disorders were diagnosed in 24 patients at a median age of 3.5 (2.6-6.0) years, 70.6% of which were diagnosed prior to the diagnosis of immunodeficiency. Lymphoproliferation, particularly hepatosplenomegaly, was significantly higher in patients with autoimmunity (p=0.004). Syndromic CID patients with autoimmunity had significantly lower IgG levels. Hematologic autoimmunity mainly immune thrombocytopenic purpura was the most frequent autoimmunity among major groups of ATM, STAT3 (AD-LOF), DNMT3B/ZBTB24, and WAS mutations, however ATM-mutated patients present more diversified involved organs including rheumatologic, gastrointestinal and dermatologic autoimmunity.ConclusionAbout 18% of patients with monogenic syndromic CIDs developed autoimmunity, mainly in the form of hematological immune diseases. Autoimmunity could be an early-onset involvement with a potential diagnostic impact on suspicious cases of syndromic CIDs.

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BackgroundAn increasing number of people have adhered to vegetarian diet since several years ago. Nowadays, the favorable effect of this dietary pattern on metabolic diseases is well established, but its impact on fertility and reproductive health as a serious health concern is not clear yet.Hence, we aim to summarize existing evidence, regarding the possible association between a vegetarian diet, and fertility as measured by key indicators such as sperm quality, and sex hormone levels.MethodsWe systematically searched online databases, including PubMed, ISI, Scopus, and Google Scholar, up to December 1st, 2022 using relevant keywords. We included observational studies that compared semen quality, sex hormone levels, and infertility in people who adhered to a vegetarian diet versus. Heterogeneity between studies was assessed using I2 and Chi‐square tests. Standardized mean differences (SMD) using a random/fixed model were calculated to assess outcomes between vegetarians and omnivores in included articles.ResultsFinally, out of 972 documents that were retrieved, 20 articles met our inclusion criteria, and 16 were eligible for quantitative synthesis. Results of meta‐analyses showed that there were no significant differences between vegetarians and omnivores in terms of semen quality parameters, including total sperm count, total and progressive sperm motility, sperm morphology, and sperm concentration. Seven studies on female sex hormones profiles were eligible for meta‐analysis. The only significant difference was the lower level of plasma estrone in vegetarians (Pooled SMD: ‐0.56; 95% CI: ‐1.08, ‐0.05; P‐value = 0.03) compared to the omnivores. Furthermore, our meta‐analysis revealed significantly higher sex‐hormone‐binding globulin (SHBG) levels in vegetarians men than in omnivores (Pooled SMD: 0.52; 95% CI: 0.18, 0.86; P‐value = 0.002).ConclusionDespite the numerous health benefits of a vegetarian diet, our review suggested that there were no conclusive positive or negative associations between vegetarian diet and semen quality, sex hormone levels, and infertility. Further studies are recommended to better understand vegetarian dietary pattern effect on infertility and reproductive health.This article is protected by copyright. All rights reserved.

Background Left ventricular pseudoaneurysm (LVPA) is a rare but life-threatening complication of myocardial infarction (MI). Given the similarities in the clinical presentations and the appearance of the cardiac imaging, differentiation of LVPA from left ventricular aneurysm (LVA) remains a challenge but is imperative for timely management. We summarized and compared clinical and imaging findings of post-MI LVPA and LVA. Method We performed a comprehensive search of the literature in PubMed and Scopus databases using combinations of key terms covering LVPA / LVA and MI. In both LVA and LVPA, individual-level patient data (IPD) and aggregated-level data (AD) studies were combined through a two-stage analysis method. Results We identified 379 eligible articles on LVPA (N= 504 patients) and 120 on LVA (n= 20,968). Based on our pooled analysis, cases were predominantly male in both groups (70.4%and 75.7 %, respectively), but LVPA patients were roughly older (Mean (95% Confidence interval (CI): (65.4 (62.4, 68.4) vs. 60.8 (58.9, 62.8) years, respectively) and had a shorter mean time interval from MI to diagnosis than LVA (5.1 vs. 27.8, months). At presentation, while 33.8 (95% CI: 22.1, 46.0) of patients with LVA had arrhythmia, only 1.0 % (95% CI: 0.0, 2.9) of LVPA patients presented with this symptom. LVPA compared to the LVA group, more frequently had ST-segment elevation (43.2% Vs. 28.6, respectively) but less frequently ECG signs of the old MI (42.2% Vs. 61.9, respectively). Echocardiography showed a lower diagnostic value in LVPA than LVA (Sensitivity: 81.4% Vs. 97.5%). Contrary to LVA, LVPA is mainly located on posterior and inferior segments based on echocardiography evaluations. On Cardiac MRI, the majority of LVPA patients had pericardial LGE (84.0% (CI 95%: 63.9, 95.5)). A higher percentage of LVPA compared to the LVA group dead during hospitalization (13.8% vs. 4.7%, respectively) or after discharge (17.5%vs. vs. 9.0%, respectively). Conclusion Arrhythmia is likely common in LVA patients at presentation but not in LVPA. LVPA is mainly located on the posterior and inferior, and LVA is on the anterior and apical segments. On cardiac MRI, pericardial LGE may suggest the presence of LVPA rather than LVA in suspected patients.

Background: Myocarditis is considered a serious adverse event after COVID-19 infection. The risk and severity of myocarditis after COVID-19 disease decreased significantly in the vaccinated population. We present a case of cardiac magnetic resonance proven fulminant myocarditis following COVID-19 disease in a young female who was previously vaccinated with 2 doses of the BIBP (Sinopharm) vaccine. Case summary: A 29-year-old female was referred to the hospital with acute chest pain, dyspnea, and nausea. Her electrocardiogram revealed ST-segment elevation in anterolateral leads with reciprocal changes in inferior leads. She was primarily diagnosed with ST-elevation myocardial infarction following spontaneous coronary artery dissection (SCAD) according to her age and gender. Her coronary angiography was normal. RT-PCR nasopharyngeal swab was positive for SARS-COV-2 infection. According to her history and excluding coronary artery diseases, she was clinically diagnosed with myocarditis and received corticosteroids, IVIG, and colchicine. She was discharged in a favorable condition after 11 days of hospitalization. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis according to the updated lake Louise criteria. On her 4-month follow-up, she was asymptomatic, and her echocardiography showed improvement in biventricular function. Discussion: The diagnosis of myocarditis caused by COVID-19 infection may be challenging as the symptoms of myocarditis, and COVID-19 disease may overlap. It should be considered when patients have acute chest pain, palpitation, elevated cardiac biomarkers, and new abnormalities in ECG or echocardiography. Cardiac MRI is a non-invasive gold standard modality for diagnosing and follow-up of myocarditis and should be used in clinically suspected myocarditis. The long-term course of myocarditis following COVID-19 disease is still unclear, but some evidence suggests it may have a favorable mid-term outcome.