Iranian Heart Journal
Volume:22 Issue: 3, Summer 2021

Mediastinitis is a severe complication after cardiac surgery. The aim of this study was to determine the incidence of postoperative mediastinitis, the predictors of mediastinitis, and sternal dehiscence in adult cardiac surgery patients.

In this retrospective study, the records of 60 patients were evaluated regarding mediastinitis and dehiscence after cardiac surgery in a referral cardiovascular hospital in Tehran, Iran.

In the present study, 4360 patients underwent surgery over 18 months from September 2017 through March 2019. Of this total, 60 patients with a diagnosis of mediastinitis and sternal dehiscence were included in the study’s analysis. In our investigation, 1.03% of the cases (45/4360) had mediastinitis and 0.3% (15/4360) cases experienced sternal dehiscence. Among the many risk factors that were examined, there were significant differences between the mediastinitis and dehiscence groups regarding diabetes mellitus (P =0.007), a history of preoperative chronic kidney disease (P =0.02), a history of myocardial infarction (P =0.002), a history of arrhythmia before cardiac surgery (P =0.02), reoperation due to postoperative bleeding (P =0.07), the number of patients transferred to the ICU with the sternum left open (P <0.001), postoperative pulmonary complications (P =0.007), and postoperative arrhythmias (P =0.04).

There were significant differences between the mediastinitis and dehiscence groups regarding diabetes mellitus, a history of preoperative chronic kidney disease, myocardial infarction and arrhythmias before cardiac surgery, reoperation due to postoperative bleeding, the number of patients transferred to the ICU with the sternum left open, postoperative pulmonary complications, and postoperative arrhythmias. (Iranian Heart Journal 2021; 22(3): 6-12)

Hepatitis C virus (HCV) infection is considered a public health problem in Egypt. The use of direct-acting antivirals (DAAs) in patients infected with HCV has been shown to be effective. The cardiac safety of these antivirals remains uncertain, however. This study aimed to assess the safety of the use of DAAs in patients suffering from ischemic heart disease (IHD) with mildly impaired systolic function.
This prospective cohort study was performed on 200 patients with chronic HCV infection scheduled for DAA use. The patients were divided into 2 groups: Group I comprised 96 patients with IHD and mildly impaired systolic function and Group II comprised 104 patients without IHD and with normal left ventricular ejection fractions. Both groups received sofosbuvir (400 mg) and daclatasvir (60 mg) daily for 12 weeks. Electrocardiography and echocardiography were performed prior to the start, during, and after 12 weeks of treatment.
At the end of the treatment period, no changes were observed in the patients’ cardiac symptoms and signs. No significant changes were also detected in electrocardiographic parameters, including the QTc interval in Group I (P =0.60) or Group II (P =0.63). Moreover, no changes were recorded in both groups regarding left ventricular systolic and diastolic functions (ie, the dimension, the ejection fraction, the transmitral E/A ratio, the E/E’ ratio, and the deceleration time), the tricuspid annular plane systolic excursion, right ventricular systolic pressure, and the mean pulmonary artery pressure.
The use of DAAs to treat Egyptian patients infected with HCV was safe in those suffering from IHD with mildly impaired systolic function. The treatment with DAAs exerted no effects on the QTc interval and the function of the left and right ventricles. (Iranian Heart Journal 2021; 22(3): 13-22)

Nuts are known for their health properties, and they play a special role in Mediterranean diets. This study aimed to determine Iranian pistachio effects on serum lipid levels in type II diabetic patients.
 
In this randomized crossover single-blind trial, 48 diabetic patients were randomly assigned to 2 groups: one that consumed 50 g of Iranian pistachios and one that followed the usual diet for 12 weeks. After an 8-week washout period, the participants were crossed over to the alternate arm.
 
Systolic blood pressure was significantly lower in the pistachio phase than the usual diet. Changes in diastolic blood pressure, lipid values (cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein), weight, and body mass index were not significantly different between the 2 intervention phases.
 
In diabetic patients, an Iranian pistachio intake (50 g daily) improved systolic blood pressure. Additionally, no detrimental effects were caused by pistachio consumption on lipid values. It seems that pistachio consumption at a high dose could change the results. (Iranian Heart Journal 2021; 22(3): 23-32)

We investigated the safety, efficacy, and follow-up results of the transcatheter closure of secundum atrial septal defects (ASDs) in children weighing less than 15 kg compared with children weighing between 15 and 20 kg.
 

During the study, 274 children weighing less than 20 kg underwent transcatheter closure. The patients were divided into 2 groups: Group I comprised 146 patients (53.3%) weighing 15 kg or less and Group II consisted of 128 patients (46.7%) weighing between 15 and 20 kg. Data were analyzed retrospectively.
 

The mean age and weight of the children were 4.3 ± 1.3 years and 15.2 ± 2.4 kg. Totally, 269 interventional operations (98.2%) were considered successful. Major complications occurred in 7 patients (2.5%). The stretched ASD diameter was 14.7 ± 3.9 (7–29) mm in Group I and 15.9 ± 4.7 (7.8–28) in Group II (P =0.063). The defect diameter/body weight was 0.9 ± 0.2 (0.4–1.8) in Group I and 0.8 ± 0.2 (0.4–1.5) in Group II (P =0.001). The Amplatzer-like device diameter was 16.0 ± 4.1 (9–30) mm in Group I and 17.7 ± 5.0 (9–34) mm in Group II (P =0.004). The patch-like device diameter was 28.8 ± 4.6 (20–35) mm in Group I and 29.4 ± 4.1 (20–33) in Group II (P =0.716). The size of the delivery sheath was 8.4 ± 1.4 (6–12) F in Group I and 8.8 ± 1.5 (6–12) F in Group II (P =0.039). There were no statistically significant differences in the rates of unsuccessful procedures and complications between the patient groups (P =0.762 and P =0.836, correspondingly).
 

The transcatheter closure of secundum ASDs in small children is feasible and is not associated with a greater risk of significant complications. (Iranian Heart Journal 2021; 22(3): 33-43)

Premature ventricular contractions (PVCs) from a right ventricular outflow origin are the first clinical presentation of an underlying arrhythmogenic right ventricular cardiomyopathy (ARVC). The association between PVCs from the other parts of the right ventricle (RV) and an underlying ARVC is unclear. This study focused on the ARVC risk in patients with PVCs originating from the RV.
 
This cross-sectional study enrolled 69 patients undergoing PVC ablation to remove the arrhythmogenic cores of the RV. Data regarding ventricular arrhythmias, symptoms, and antiarrhythmic drug consumption were gathered. The subjects were recalled for follow-up evaluations using electrocardiography and echocardiography to diagnose cases affected by ARVC. The data were analyzed using SPSS, version 20.
 
Among the participants, 5.8% of the cases were diagnosed with suspected ARVC. The origins of the arrhythmogenic foci were as follows: the right papillary muscles in 11 patients, the moderator bands in 2, the right ventricular outflow tract (RVOT) free wall in 23, the RV low septal wall in 2, and the tricuspid annulus in 31. RVOT dimensions exhibited a meaningful increase over time (P =0.01). The severity of tricuspid regurgitation also increased meaningfully over time (P =0.04).
 
Many patients undergoing ablation therapy on the RV for the treatment of arrhythmogenic foci are at an increased risk of ARVC, and they could exhibit PVCs originating from the other parts of the RV, necessitating robust observation. Increased RVOT dimensions and worsening tricuspid regurgitation should be an alarming sign in these cases. (Iranian Heart Journal 2021; 22(3): 44-52)

Mediastinal and epicardial adipose tissues are correlated with several adverse metabolic effects and cardiovascular diseases, especially coronary artery disease (CAD). The manual measurement of these fat tissues is widely done in clinical practice due to its human efficacy. As a result, the automated measurement of cardiac fats could be considered one of the most important biomarkers for cardiovascular risks in imaging and medical visualization by physicians.
 
In this cross-sectional study, 2 non-contrast computed tomography (CT) data sets were used. An algorithm was designed based on data from 20 patients for cardiac fat measurement. One hundred twenty patients were examined to determine the relationship between CAD and the volume of cardiac fats using coronary artery calcium scoring assessment.
 
In the examination of the correlation between CAD and the volume of cardiac fats, coronary artery stenosis was severe in 11 patients (9.2%), moderate in 15 patients (14.2%), and mild in 17 patients (14.2%); additionally, no coronary artery stenosis was detected in 77 patients (64.2%). Cardiac fat was measured with an accuracy of 99.2%, and the best threshold obtained an epicardial fat volume (EFV) of 140 mL and a mediastinal fat volume (MFV) of 94 mL for having the largest correlation. In addition, with the increment in the severity of CAD, there was a considerable increment in cardiac fat volume and a significant linear correlation between coronary artery stenosis and MFV (r =0.36; P <0.001) and EFV (r =0.322; P <0.001).
 
Cardiac fat tissues could be utilized as a trustworthy biomarker tool to predict the extent of CAD stenosis. (Iranian Heart Journal 2021; 22(3): 53-63)

Cardiovascular diseases are the first and the most common cause of death in Iran. Pentraxin3 (PTX3) is an inflammatory marker that increases in patients with acute myocardial infarction. This study aimed to compare the PTX3 level among patients with acute coronary syndrome (ACS).
 
The present study enrolled 130 patients with ACS and 82 subjects as the control group. Within 12 hours of the onset of chest pain, 5 mL of blood was obtained from the antecubital vein. Then, serum was separated by centrifugation and stored at –70 °C until the measurement of PTX3. The level of PTX3 was measured using an enzyme-linked immunosorbent assay kit. Data were recorded and analyzed by SPSS version 16.0. A P-value of less than 0.05 was considered statistically significant.
 
The distribution of age, sex, diabetes mellitus, hypertension, and hyperlipidemia was similar in both the ACS and control groups, but it was not similar for smoking. Serum PTX3 was significantly higher in the ACS group. The serum PTX3 level was higher in the subgroup with ST-segment elevation myocardial infarction than in the subgroups with unstable angina pectoris, stable angina pectoris, and noncardiac diseases. Additionally, patients with unstable angina pectoris had higher PTX3 than those with stable angina pectoris and noncardiac diseases.
 
Our results suggest that PTX3 may be released by systemic inflammation at the very onset of acute myocardial infarction. (Iranian Heart Journal 2021; 22(3): 64-73)

Given that insomnia is common and not always easily handled after coronary artery bypass graft surgery (CABG), this study was conducted to compare the efficacy of quetiapine and alprazolam in post-CABG insomnia.
 
In this clinical trial, 90 patients undergoing CABG were selected and randomly divided into 2 groups of 45 patients. The first group received 12.5 mg of oral quetiapine and the second group received 0.5 mg of alprazolam before bedtime (at 10 PM). The patients’ insomnia was evaluated and compared using the Insomnia Severity Index (ISI) questionnaire on 3 occasions: 1 month before surgery and then 3 days and 14 days after surgery.
 
The mean score of insomnia 1 month before surgery and 3 days after surgery had no statistically significant difference in both groups (P =0.89 and P =0.55, respectively). The mean score of insomnia on the 14th postoperative day, which was at the end of the 10-day treatment period, was 15.33 ± 3.87 in the alprazolam group and 13.33 ± 4.71 in the quetiapine group (P >0.05 and P =0.043, respectively). In the quetiapine group, 2 patients experienced drowsiness on the following day and 1 patient developed pruritus; none of them experienced restless leg syndrome or dystonia. Nine patients in the quetiapine group and 3 patients in the alprazolam group had drug noncompliance.
 
Despite more drug noncompliance, very low-dose quetiapine was more effective than alprazolam in improving the sleep quality of our early postoperative CABG patients.  (Iranian Heart Journal 2021; 22(3): 74-80)

The gold standard for the diagnosis of pulmonary arterial hypertension (PAH) is right heart catheterization (RHC). The use of noninvasive echocardiographic methods to assess the pulmonary artery pressure (PAP) has been debated, and the role of echocardiography has been proposed to be more of estimating the probability of PAH rather than assessing the pressure. In this study, we assessed the accuracy of the use of pulmonary regurgitant (PR) and tricuspid regurgitant (TR) velocities in estimating PAH by comparison with RHC in patients with right ventricular dysfunction.

This cross-sectional study was performed in Rajaie Cardiovascular Medical and Research Center from 2015 through 2016. We selected patients with right ventricular dysfunction who were candidates for RHC. Echocardiography was performed within 24 hours before catheterization. PAH was estimated by using PR and TR velocities. The correlation between echocardiography and catheterization-derived PAH was tested by using the Pearson correlation test.

There was significant accordance between the 2 tools in terms of the measurement of the systolic PAP (r =0.860, P <0.001), the diastolic PAP (r =0.793, P <0.001), and the mean PAP (r =0.739, P <0.001) in the diagnosis of PAH (Κ =0.964, P <0.001). Based on the receiver operating characteristic curve analysis, the measurement of the TR velocity had a moderate value in predicting PAH (the area under the curve =0.622). The best cutoff value for the TR velocity in predicting PAH was 3.27, yielding a sensitivity of 72.1% and a specificity of 50.0%.

Echocardiography-derived measurements were in good correlation with RHC in the assessment of PAH in our patients with right ventricular dysfunction. (Iranian Heart Journal 2021; 22(3): 81-87)

Heart failure (HF) is a complex clinical syndrome estimated to have afflicted 23 million people worldwide. This study aimed to measure syndecan-1 and neurotrimin levels in patients with decompensated heart failure (DHF) admitted to the emergency department.
 
This study was conducted from November 2017 through June 2018 in Imam Khomeini Hospital, a referral center in Ahvaz, Iran. Baseline demographics were recorded. The Human Syndecan-1/CD138 (SDC1) ELISA kit for the measurement of syndecan 1 and the Human Neurotrimin ELISA kit for the measurement of neurotrimin (ZellBio GmbH, Berlin, Germany) were used. The detection range for syndecan 1 and neurotrimin was 1.5 to 48 ng/mL and 0.4 to 12.8 ng/mL, respectively.
 
Seventy-two patients met the study inclusion criteria. The mean level of syndecan 1 and neurotrimin was 24.31 ± 8.27 ng/mL (11–37 ng/mL) and 0.52 ± 0.19 ng/mL (0–9 ng/mL), respectively. The results showed no correlations between the severity of illness and syndecan-1 and neurotrimin levels, nor were there any correlations between age, sex, blood urea nitrogen, creatinine, the estimated glomerular filtration rate, and B-type natriuretic peptide (in DHF >500 ng/mL) and the levels of syndecan 1 and neurotrimin (P >0.05).
 
The syndecan-1 level did not change in patients suffering from HF with reduced ejection fraction (EF). Further, patients in any EF classification had a low level of neurotrimin. However, no significant associations were found between the classes of the EF and the serum neurotrimin level. (Iranian Heart Journal 2021; 22(3): 88-94)

Myocardial perfusion imaging (MPI) via gated single-photon emission computed tomography is an effective tool in the evaluation of left ventricular (LV) perfusion and function. The purpose of this study was to determine the association between stress-induced left ventricular diastolic dysfunction (LVDD) and ischemic heart disease (IHD) via MPI.
 
The present study recruited 103 patients, all of whom underwent a standard 2-day stress/rest gated MPI study according to predefined protocols. Perfusion quantitative and semiquantitative indices and diastolic functional parameters were recorded.
 
The study population comprised 88 male patients (85%) and 15 female patients (15%) at a mean age of 56.3 ± 10.7 years. The thresholds of stress-induced LVDD were calculated as post-stress to rest differences in diastolic parameters and defined as a reduction of 0.21 end-diastolic volumes per second (EDV/s) in the peak filling rate (PFR), an increase of 0.32 in the PFR2/PFR ratio, and an increase of 25 milliseconds of time-to-peak filling. The patients were categorized into 2 groups based on the presence or absence of stress-induced LVDD. The comparison of perfusion parameters depicted no significant changes between the 2 groups (all P-values >0.05). No significant differences were also detected concerning IHD burden (P =0.714).
 
Although LV diastolic dysfunction is deemed one of the earliest indicators of coronary artery disease, we found no significant association between stress-induced LVDD and the burden of IHD. (Iranian Heart Journal 2021; 22(3): 95-103)

The coronavirus disease 2019 (COVID-19) outbreak continues to spread worldwide, hence the increasing attention to the predictors of mortality. However, there is no easy prognostic risk score to predict in-hospital mortality.We aimed to assess the efficacy of the right ventricular early inflow-outflow index (RVEIO) as a predictor of early mortality in patients with thromboembolism. Additionally, we assessed acute respiratory distress syndrome, which is deemed a complication of COVID-19 and an etiology of acute cor pulmonale.

This single-center, observational cross-sectional study assessed laboratory data and electrocardiographic and echocardiographic findings of patients with a diagnosis of COVID-19 based on a positive polymerase chain reaction test and lung involvement exceeding 20% in the non-intensive care units of our hospital.

The study population comprised 360 patients (mean age=54.46 y, 61.1% male). The mean RVEIO index was 3.40 ± 1.14, the mean right ventricular peak systolic myocardial velocity (RVsm) was 12.29 ± 3.81 cm/s, and the mean tricuspid annular plane systolic excursion (TAPSE) was 22.41 ± 4.97 cm. No significant difference was found in the RVEIO index between the patients who were discharged and those who expired (3.26 ± 1.25 vs 3.31 ± 1.29, respectively), nor was there a correlation between the RVEIO index and admission to the intensive care unit. The RVEIO index was not a predictor of RV dysfunction, as assessed by RVsm and TAPSE. Patients who suffered from myocardial infarction had a significantly higher RVEIO index.

None of the echocardiographic findings, including the RVEIO index, was an accurate predictor of RV dysfunction, mortality, and inflammation levels in our patients with COVID-19. Accordingly, they should not be relied upon for clinical decision-making and management. (Iranian Heart Journal 2021; 22(3): 104-114)

Aneurysmal formation in the membranous part of the interventricular septum is a very rare heart defect. The interventricular membranous septal (IVMS) aneurysm is mainly found in conjunction with ventricular septal defects or other congenital cardiac anomalies. It has often been found as an asymptomatic phenomenon, so that it is diagnosed incidentally during imaging evaluations of heart structures. Thereby, its presence without other congenital cardiac anomalies is a very uncommon entity. Herein, we describe a 77-year-old man with the chief complaints of chest pain and dyspnea on exertion. The physical examination was normal except for the presence of ejection-type systolic murmurs along the left sternal border in the aortic area on auscultation. The patient’s preoperative transthoracic echocardiography revealed severe aortic valve stenosis, and his transesophageal echocardiography during aortic valve replacement revealed an incidental IVMS aneurysm. The aneurysm was resected concomitantly with aortic valve replacement surgery, and he was asymptomatic and stable in the follow-up period. (Iranian Heart Journal 2021; 22(3): 115-118)

Uremic pericarditis is a major complication of acute or chronic end-stage renal disease (ESRD). A significant cause of morbidity and mortality in most hemodialysis programs, uremic pericarditis can occur before dialysis or on dialysis. The causes of uremic and dialysis pericarditis remain uncertain. Accurate hemodialysis and pericardiocentesis result in marked improvements. The diagnosis of uremic pericarditis, in addition to other causes such as idiopathic, malignant, coagulopathy, and tuberculous pericarditis, should, therefore, be considered in the differential diagnosis for cases presenting with hemorrhagic pericardial effusion. Here, we describe a 50-year-old man, who presented with shortness of breath and altered levels of consciousness of 5 days’ duration with a history of hypertension, diabetes, and ESRD on hemodialysis over the past 5 years. The patient was admitted to our hospital with a diagnosis of acute massive hemopericardium secondary to uremic pericarditis after staining and cytology detected an exudate pericardial effusion despite no evidence of infection (eg, tuberculosis) or malignancy. He was admitted into the intensive care unit and successfully managed with hemodialysis and pericardiocentesis. (Iranian Heart Journal 2021; 22(3): 119-122)

Wilson’s disease is a disorder of copper metabolism that results in the accumulation of copper in various body tissues. The most common organs involved in this disease are the liver and the brain, with most of the clinical symptoms being related to these 2 organs. Albeit less affected, the cardiovascular system is also involved. In this paper, we aim to report a very rare cardiac complication of Wilson’s disease. 1 (Iranian Heart Journal 2021; 22(3): 123-127)

Thrombus formation within the left ventricular apex is a well-known clinical condition that is often associated with underlying myocardial diseases, whereas thrombus formation in the right ventricle (RV), albeit a potentially fatal clinical condition, is not very well known. Thrombus formation around the heart cavities is dangerous since it may lead to systemic and pulmonary embolism. Hypercoagulation states, RV infarction, pulmonary embolism, autoimmune diseases, and dilated cardiomyopathy are some other potential risks. Transthoracic echocardiography is the modality of choice for the diagnosis and characterization of such thrombi in that it allows differentiation between various types of thrombi. We herein describe a patient with an unknown history of constrictive pericarditis and a concomitant RV mass in the RV apical aneurysm, which was initially suspected to be a thrombus. We learned from the patient’s history that he had previously received irregular treatment for tuberculosis. (Iranian Heart Journal 2021; 22(3): 128-130)