Iranian Heart Journal
Volume:21 Issue: 4, Fall 2020

Cardiovascular morbidity and mortality represent a special concern in a patient with known or unknown cardiovascular disease undergoing high-risk noncardiac surgeries such as major vascular surgery.

Over a period of 36 months, from 2010 to 2013, we enrolled 65 patients in the Vascular Surgery Department of Imam Reza University Hospital. To assess the patients before major vascular surgery, we performed electrocardiography and echocardiography; and depending on these modality findings, some of the patients were candidated for the exercise test, thallium scan, and coronary angiography. During surgery, the patients had cardiac monitoring; and after surgery, they underwent cardiac monitoring, echocardiography, and cardiac troponin tests.

In the entire study population, the prevalence rate of perioperative ischemia was 18.5%, myocardial infarctions 4.6%, and arrhythmias 6.4% and hypotension 9.2% in the operating room. The prevalence of death owing to cardiac events during surgery was 4.6% in the whole study population. Additionally, 27.7% of the patients had no perioperative cardiac events. In the comparison of the risk factors, hypertension (72.2% vs 57.4; P = 0.021), diabetes (50% vs 19.1%; P = 0.017), smoking (62% vs 40%; P = 0.05), and previous ischemic heart diseases (58.5% vs 31.5%; P = 0.042) were more common in the patients with cardiac events.

Perioperative cardiac assessments and cardiac risk factor modifications may be considered in major vascular surgery. Close cardiac monitoring during and after surgery plays a significant role in decreasing cardiac events. (Iranian Heart Journal 2020; 21(4): 6-13)

The effects of L-carnitine on serum lactate and its metabolism remain uncertain, particularly in candidates for revascularization with a high likelihood of a postoperative rise in lactate levels. The present study aimed to assess the effects of L-carnitine on lactate levels after coronary artery bypass graft surgery (CABG) in patients with grade I heart failure.  

in this randomized clinical trial, 64 consecutive patients suffering from mild heart failure (grade I) who were candidated for coronary revascularization were randomly divided into 2 groups (32 patients in each group) receiving L-carnitine (3 g orally 2 hours before surgery) or a placebo for the same duration before surgery.  Postoperative adverse events, as well as the trend of the change in the levels of serum lactate, creatinine, and hemoglobin, within 24 hours after surgery were assessed.  

No difference was revealed between the 2 groups in terms of serum lactate levels before surgery (1.51 ± 0.79 in the intervention group vs 1.35 ± 0.43 in the control group; p = 0.33), during intra-aortic balloon pumping (2.27 ± 1.28 in the intervention group vs 2.70 ± 1.42 in the control group; p = 0.20), and also after separating the pump (2.96 ± 1.61 in the intervention group vs 2.56 ± 0.87 in the control group; p = 0.22). No difference was also observed concerning postoperative complications, including atrial fibrillation (p = 0.42), delirium (p = 0.99), agitation (p = 0.88), intra-aortic balloon pump insertion (p = 0.99), atelectasis (p = 0.98), and respiratory distress (p = 0.99).  

Administrating L-carnitine had no protective effects on the rise in postoperative serum lactate levels following CABG in our patients with low-grade heart failure. (Iranian Heart Journal 2020; 21(4): 14-24)

Advanced monitoring can lead to the early recovery of patients in complicated and high-risk surgical operations. The aim of this study was to evaluate the effects of advanced monitoring on the hemodynamics of patients undergoing cardiac surgery.

In this study, patients undergoing cardiac surgery were divided into 2 groups of control and advanced monitoring. In each group, 25 patients were examined. The patients had moderate-to-severe left ventricular dysfunction (ejection fraction < 35%). The patients in the case group were placed on the FloTrac cardiac output monitor, which is used as a therapeutic guide in the operating room and the intensive care unit (ICU).

Upon ICU admission, the average stroke volume variation and the mean cardiac index in the advanced monitoring group in the first 6 hours were 10 and 2.7, respectively, and in the second 6 hours were 11 and 2.8, correspondingly. The mean serum level administered was 1000 cc in the first 6 hours and 500 cc in the second 6 hours. In the control group, the mean serum level administered was 2000 cc in the first 6 hours and 500 cc in the second 6 hours, which had a significant relationship between the 2 groups in the first 6 hours (P = 0.01). Additionally, 84% of the patients with advanced monitoring were extubated in the first 6 hours (P = 0.0).

This study showed that cardiac surgery in patients with moderate-to-severe left ventricular dysfunction using advanced monitoring and goal-directed hemodynamic therapy based on the cardiac index, the stroke volume variation, and the stroke volume index reduced the duration of intubation after surgery. (Iranian Heart Journal 2020; 21(4): 25-32)

Cardiac arrhythmias are identified as the major cause of mortality and morbidity in neonates. Most term and preterm infants admitted to the neonatal intensive care unit (NICU) suffer from respiratory diseases, and generally aminophylline as a nonselective phosphodiesterase inhibitor is used. Although aminophylline has several physiological effects on the heart tissue, it has been recognized to have some side effects. Neonates are more prone to its cardiac side effects, notably arrhythmias.

This study aimed to evaluate and compare the effects of fast and slow aminophylline injections on electrocardiographic parameters and arrhythmias in neonate rats.

Thirty-two male Sprague-Dawley rats (10 days old, 50 g) were divided into 4 groups (8 in each): Group I and Group II were treated with 5 mg/kg of normal saline intravenously for 3 and 20 minutes, correspondingly, and Group III and Group IV were treated with a 5-mg/kg bolus of aminophylline intravenously for 3 and 20 minutes, respectively. On the experiment day, the rats were anesthetized with a mixture of ketamine (50 mg/kg) and xylazine (10 mg/kg) with intraperitoneal injection, and lead II electrocardiograms were recorded. The femoral vein was cannulated using polyethylene catheters (PE50) for the intravenous injection of aminophylline (5 mg/kg) or normal saline.

The rats receiving aminophylline showed a dramatic reduction in the heart rate. Additionally, the PR interval and QTc significantly increased in the rats receiving aminophylline for 3 minutes. Moreover, complete heart blocks, premature ventricular beats, atrioventricular blocks (Mobitz I and Mobitz П), sustained and nonsustained ventricular tachycardias, and AV dissociations were observed.

The results of the current study indicated that a slow infusion rate could prevent the cardiac complications of aminophylline, particularly arrhythmias, in neonate rats.(Iranian Heart Journal 2020; 21(4): 33-42)

The early diagnosis of heart failure in patients with hypertrophic cardiomyopathy (HCM) remains a challenge. In this study, we sought to evaluate cardiac mechanics in patients with HCM.

Sixty patients (60% men, mean age = 45.8 ± 17 y) with documented HCM were identified from an ongoing clinical registry.

The values of maximal left ventricular (LV) wall thickness, the ejection fraction (EF), global the longitudinal strain (GLS), and the global circumferential strain (GCS) were 2.2 ± 0.5 cm, 54.1 ± 6.5%, −15.3 ± 4.5%, and −26.9 ± 7.5, consecutively. Cardiovascular magnetic resonance imaging (CMR) data on 34 patients were included in the analysis. Nearly half of the patients had obstructive HCM; and in comparison with nonobstructive HCM, there were no significant differences in terms of GLS, GCS, EF, and the New York Heart Association Functional Class (NYHA FC). EF was similar between the 2 NYHA FC groups (I and II vs III and IV). GLS had a meaningful difference between the NYHA FC groups. In patients with a late gadolinium enhancement (LGE) value of equal to or greater than 15%, EF, GLS, and GCS were correlated and reduced.  Additionally, in those with an LGE value of between 5% and 15%, EF was preserved with a reduced GLS. GLS was worse in patients with an E/average E′ ratio of equal to or greater than 14.

Our study showed that an increased LV wall thickness and/or a reduced LV end-diastolic volume, with better GCS, maintained a normal EF despite a reduced GLS. GLS had a better correlation with NYHA FC and LGE in CMR than EF alone. (Iranian Heart Journal 2020; 21(4): 43-59)

Generally, 2 types of surgical operations are available for the treatment of cyanotic heart diseases: corrective and palliative. The goal of palliative surgery is to increase the pulmonary blood flow via systemic-to-pulmonary arterial shunting.  

In this case-series study, we evaluated patients older than 15 years old with documented cyanotic heart diseases who underwent palliative shunting in Rajaie Cardiovascular Medical and Research Center between 2001 and 2015.  

Forty-seven patients at a mean age of 24.74 ± 5.67 years were enrolled in this study. Twenty-two (46.8%) patients were male. Nearly half of the study population (23 patients) had central shunting, 23 patients Glenn shunting, and 1 patient Blalock–Taussig shunting. Following surgery, there was a significant rise in the mean partial pressure of O2 and O2 saturation, a significant drop in the hemoglobin concentration, and a significant increase in the platelet count. Five (10.6%) patients expired during the study period. The mortality rate of Blalock–Taussig shunting and Glenn shunting was 12.5% and 8.69%, respectively.  

In this case-series study, all the patients showed dramatic improvements in the New York Heart Association functional class, O2 saturation, the partial pressure of O2, the partial pressure of carbon dioxide, hemoglobin levels, and ferritin levels in the first postoperative year; however, these improvements were greater in arterial shunts. The following 10 years saw a decline in these improvements; nonetheless, the clinical status and lab data were good by comparison with the baseline. In adults with congenital cyanotic heart diseases, palliative shunting is a good option and should be considered in patients who are inoperable due to structural problems or high risk of anesthesia or surgery. (Iranian Heart Journal 2020; 21(4): 60-66)

One of the probable reasons for wall motion polar map abnormalities is left ventricular (LV) dyssynchrony. The objective of this study was to evaluate LV dyssynchrony via the phase analysis on myocardial perfusion imaging (MPI) in patients with a low pretest probability of ischemic heart disease (IHD) and normal electrocardiography (ECG)-gated MPI as the possible contributor to LV regional wall motion polar map abnormalities.

A total of 181 patients with a low likelihood of IHD, normal MPI, a normal global function, and a normal global ejection fraction were divided into 2 groups: Group A: 81 patients with abnormal regional wall motion and Group B: 100 patients with normal wall motion polar maps. Dyssynchrony in the LV wall was assessed in terms of the phase analysis indices of entropy, the phase histogram bandwidth, and the phase standard deviation quantified by quantitative gated SPECT software, and the results for both groups were compared.

The mean entropy values in the LV anterior, lateral, inferior, and particularly septal walls (P < 0.0001), as well as the mean entropy value in the LV apical wall (P = 0.030), in Group A were significantly higher than those in Group B. Moreover, the phase histogram bandwidth and the phase standard deviation were considerably higher in Group A than in Group B in all LV walls (P < 0.0001), except the LV apical wall (P = 0.063 and P = 0.036) respectively.

Assessment of the phase analysis indices for LV dyssynchrony could be used in patients with a low probability of IHD, a normal LV perfusion, and abnormal wall motion polar maps as a complementary tool for the interpreting physician. (Iranian Heart Journal 2020; 21(4): 67-75)

Postoperative gastrointestinal complications are important in that they lead to increased lengths of hospitalization in the intensive care unit (ICU) and mortality among patients undergoing surgery on cardiopulmonary bypass (CPB). It appears that such gastrointestinal complications may be correlated with the postoperative serum level of amylase among patients. We aimed to determine the relationship between the mean arterial pressure (MAP) during CPB and changes in the postoperative serum level of amylase.

In this observational study, 164 adult patients who underwent cardiac operations and were transferred into the ICU of Rajaie Cardiovascular Medical Research Center (Tehran, Iran) were enrolled via convenience sampling. The patients’ demographic and clinical data, as well as hemodynamic parameters including MAP, were measured during and after CPB in the ICU. Serum amylase levels were assessed after anesthesia induction, after CPB, 12 and 24 hours after CPB.

The mean serum level of amylase significantly increased after CPB and continued 24 hours after ICU admission. There was no statistically significant relationship between MAP during CPB and the serum amylase level immediately after CPB and at 12 and 24 hours after ICU admission. A significant relationship was found between gender and age and a serum level of amylase of greater than 125 IU/L at 12 and 24 hours after CPB.

The serum level of amylase increased after CPB up to 24 hours following ICU admission. There was no significant relationship between MAP during CPB and the serum amylase level after cardiac surgery. (Iranian Heart Journal 2020; 21(4): 76-84)

Reoperation due to bleeding in adult cardiac surgeries is an important postoperative complication that increases mortality and morbidity. Studying the risk factors and outcomes of reoperation in these patients is imperative.

The present descriptive (cross-sectional) study performed a 3-month assessment of patients that underwent elective cardiac surgeries (coronary or valve surgeries or both). The inclusion criterion was being an adult undergoing elective cardiac surgeries on cardiopulmonary bypass (coronary or valve surgeries or both), and the exclusion criteria consisted of congenital heart diseases, cardiac surgeries without cardiopulmonary bypass, emergency cardiac surgeries, aneurysm and aortic dissection surgeries, known causes of bleeding due to acquired or congenital diseases, and redo cardiac surgeries.

Of 740 patients studied, 55 (7.43%) patients returned to the operating room due to bleeding. Of these 55 patients, 74.5% had bleeding due to surgical operations, 23.6% due to tamponade, and 1.8% due to coagulation disorders. Apropos risk factors, there was a significant relationship between the international normalized ratio (INR) and bleeding after cardiac surgeries leading to reoperation (P = 0.05).

In this study, 7.43% of the patients returned to the operating room because of bleeding, which is an acceptable percentage according to the literature. There was a significant relationship between preoperative INR and postoperative bleeding resulting in reoperation. (Iranian Heart Journal 2020; 21(4): 85-92)

Coronary artery disease is the leading cause of mortality worldwide. With the increasing number of elderly people and the development of stents, the tendency to perform percutaneous procedures has increased, leading to an increased risk of complications known as major adverse cardiovascular events (MACE). This study aimed to assess the association between demographic, laboratory, and angiographic findings and MACE in patients undergoing elective angiography.

This cross-sectional descriptive study enrolled 300 patients older than 18 scheduled for elective angiography in Rajaie Cardiovascular Medical and Research Center between 2015 and 2016. Those who did not undergo stenting or needed surgery initially were excluded, leaving 207 patients. The demographic, laboratory, and angiographic data of these patients were collected, and they were then followed for 2 years.

During a mean follow-up of 24 months, MACE occurred in 20 (9.60%) patients, with 1 patient experiencing 2 events. There was significant relationships between older age (P = 0.01), the female gender (P < 0.0001), the body mass index (P < 0.0001), total cholesterol (P = 0.01), low-density lipoprotein (P = 0.001), high-density lipoprotein (P = 0.003), triglycerides (P = 0.014), hemoglobin (P = 0.004), lower glomerular filtration rates (P < 0.0001), higher post-angiography troponin I (P < 0.0001), and fasting blood sugar (P < 0.0001) and MACE. There were also relationships between the incidence of cardiovascular diseases and the number of diseased vessels (P = 0.047) and between the need for repeated revascularization and the number of vessels (P = 0.01).

As many MACE risk factors are modifiable, we suggest that patients with the aforementioned risk factors be monitored more closely after percutaneous coronary interventions to predict and prevent the incidence of MACE. (Iranian Heart Journal 2020; 21(4): 93-102)

Dilated cardiomyopathy (DCM) is one of the most common causes of heart failure. More than 40 genes with different strengths are involved in its pathogenesis. The second most important gene in DCM pathogenesis is the LMNA gene. LMNA has 12 exons and encodes Lamin A and Lamin C. This study aimed to screen any mutation that occurs in exons 4 and 5 of this gene in patients suffering from DCM.

Thirty patients with DCM were enrolled in this study. A control group was formed from 30 normal participants. After DNA extraction, polymerase chain reaction (PCR) was performed to amplify desired DNA fragments. Then, the amplified fragments were sequenced via the Sanger technique. The obtained sequences were statistically analyzed using the SPSS software, version 24.

In exon 5, in 23.3% (n = 7) of the patients, 1 substitution mutation (c.861 T>C; rs538089) was detected. All the patients were heterozygous for this variant. The frequency for mutated alleles was significantly higher in the patients than in the normal controls (χ2 = 4.821; P = 0.028). No mutation was observed in exon 4 both in the patient and control groups.

Although rs538089 is a synonymous mutation, its predominant existence in the LMNA gene of our patients was interesting, as was its association with the female gender. It could be assumed that this variant may play a potential role in DCM. (Iranian Heart Journal 2020; 21(4): 103-110)

The purpose of this study was to clarify the dynamics of heart rate variability (HRV) in the dynamics of alcohol withdrawal syndrome relief.

We examined 31 patients at an average age of 43.9 ± 5.2 years with alcohol withdrawal syndrome (the middle stage, the period of maintenance therapy) and 15 volunteers of comparable age. The control points for assessing HRV were 1 to 2, 3 to 5, 6 to 9, and 10 to 15 days after stopping alcohol consumption. Electrocardiography was performed using the software and hardware complex Polyspectr-12 (Neurosoft, Russia). HRV was evaluated using a set of statistical and spectral analytical methods, including the coefficient of variation (%), and spectral analysis indicators (based on the fast Fourier transform algorithm using all points without smoothing). The geometric analysis of the cycles of nonlinear cardiac rhythm waves was performed using a chaos test via the method of Gavrilushkin (2007).

In our patients with alcohol withdrawal syndrome in the rehabilitation period, there was a pronounced instability of the heart rhythm, which was manifested in the increasing role of its intracardiac regulation mechanisms and the stimulating effect of sympathicotonia. The most pronounced shifts in HRV were detected in the period from 3 to 9 days after the cessation of alcohol consumption. Additionally, the risk of arrhythmogenic complications in alcohol withdrawal syndrome was highest from the third to the ninth day of the rehabilitation period.

Our patients with alcohol withdrawal syndrome in the rehabilitation period exhibited a pronounced instability in their heart rhythm, manifesting itself in the increasing role of its intracardiac regulation mechanisms and the stimulating effect of sympathicotonia.(Iranian Heart Journal 2020; 21(4): 111-117)

We aimed to identify the predictor of developing significant mitral regurgitation (MR) after repeated percutaneous balloon mitral valvuloplasty (PBMV) via the Inoue Balloon Technique in middle-aged and elderly patients.

This prospective study was performed on 40 patients presenting to the cardiology department with severe symptomatic mitral restenosis following previous PBMV via the Inoue Balloon Technique. Informed written consent was obtained from all the patients. MR was evaluated before and after PBMV and subsequently at short-term follow-up.

The study population was aged above 45 years. The 40 patients recruited were divided into 2 main groups: Group A comprised 28 patients who did not develop an increase in the grade of MR at follow-up and Group B consisted of 12 patients who developed at least a 1-grade increase in MR at follow-up. The results were compared before, after, and at short-term follow-up between the 2 study groups. The forward stepwise logistic regression analysis identified the presence of preprocedural Grade I MR as the most important independent predictor of the development of MR after PBMV (P = 0.01). No significant difference was observed between the study groups concerning symptomatic and hemodynamic improvements after PBMV.

The presence of preprocedural Grade I MR may be the most independent predictor of a rise in the MR grade following repeated PBMV in middle-aged and elderly patients. (Iranian Heart Journal 2020; 21(4): 118-130)

Cor triatriatum, first described by Church in 1868, is an extremely rare congenital cardiac defect and accounts for between 0.1% and 0.4% of all congenital cardiac anomalies. Isolated cor triatriatum is rare and is usually associated with other cardiac anomalies, most commonly the atrial septal defect (ASD). Although the clinical presentations of cor triatriatum depend on the size of the fenestration, almost all cases are diagnosed in childhood and very few cases remain asymptomatic until adulthood. Several techniques such as transthoracic echocardiography, transesophageal echocardiography, computed tomography, and magnetic resonance imaging are used for the diagnosis of cor triatriatum; nevertheless, the definitive diagnosis and the identification of the associated anomalies can be easily made by echocardiography. The use of computed tomography is associated with the risk of radiation, and transesophageal echocardiography has the discomfort of scope intubation. 5
We herein describe a 35-year-old pregnant woman with no previously described cardiac disorder who was diagnosed with cor triatriatum dextrum presenting with shortness of breath, tachycardia, and palpitation of 1 week’s duration. She had a history of 5 uncomplicated vaginal deliveries. (Iranian Heart Journal 2020; 21(4): 131-134)

Coronaviruses are a large family of RNA viruses, the most pathogenic of which are SARS-CoV, MERS-CoV, and the newest type, SARS-CoV-2. 1 Since the start of the recent spread of the coronavirus in the world, the number of patients with cardiovascular diseases referring to emergency departments has decreased due to various reasons. However, many of the patients who do refer to emergency departments may have the complications of coronavirus disease 2019 (COVID-19). We herein describe a patient who was admitted with an acute coronary syndrome after having developed the symptoms of coronavirus and was eventually diagnosed with acute Type A dissection. (Iranian Heart Journal 2020; 21(4): 135-139)