Iranian Heart Journal
Volume:6 Issue: 4, Winter 2005

The frequency of left atrial thrombus and the effect of anticoagulation on LA clot in patients with mitral stenosis (MS) are not well established. Resolution of left atrial thrombus after a period of oral anticoagulation results in safe percutaneous mitral commissurotomy (PMC). However, whether the persistent presence of left atrial appendage (LAA) clots after a short period of oral anticoagulation increases the embolic risk is not well defined. This study was designed to document the occurrence rate of left atrial thrombus in patients with mitral stenosis and to assess the effects of short-term of oral anticoagulation on clot dissolution. In addition, it sought to evaluate the safety of PMC in patients with MS after warfarin therapy. 182 consecutive patients with moderate-to-severe and severe mitral stenosis who were candidates for percutaneous mitral commissurotomy underwent both a baseline transthoracic (TTE) and transesophageal (TEE) echocardiography. All the cases with left atrial appendage thrombi received oral warfarin. Follow-up TEE study was performed after 2-3 months of anticoagulation. Of 182 consecutive patients with MS, 31 cases (17.03%) had left atrial appendage clot. In one patient (0.42%), a pedunculated clot was seen at the mouth of the left atrial appendage and left atrial cavity. Complete resolution of thrombus was demonstrated in 24 patients (77.5%), and partial clot lysis was seen in 4 cases (13%). In 3 cases (9.5%), no significant change in the size of clot was observed. All of these 31 patients underwent PMC successfully without any embolic complication. Despite the emphasis on long-term warfarin therapy before PMC (at least 6 months), we maintain that a short period of anticoagulant therapy offers complete or partial resolution of LAA clot. In addition, PMC could be performed safely in patients with mitral stenosis even in the presence of left atrial appendage clot after this period of anticoagulation with no additional risks of embolic complication.

Coronary artery disease (CAD) usually occurs in the middle age group. However, recently a significant proportion of this disease occurs in young patients aged less than 45 years. There is still controversy whether the young patients have a high prevalence of some risk factors and whether their nature of disease is more aggressive. This study compared the profile of distribution of major risk factors between patients aged less or older than 45 years of age with acute myocardial infarction. We conducted a cross-sectional study based on hospital charts of 1236 patients with diagnosis of myocardial infarction who were hospitalized consecutively at our department between 1991 and 2001. The data of age, gender and major risk factors such as diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, hypertension and smoking status were collected using hospital charts. The results showed that out of the 1236 cases, 105 (8.5%) occurred in patients aged less than 45 years (10.5% of the males and 5.3% of the females, P=0.03). Overall, 62% of the patients were male and 38% female. Among major risk factors studied, the prevalence of smoking and hypertriglyceridemia was more common in the less-than-45-year-old age group in comparison with the second group (42.2% vs. 29.7%, P=0.009 and 17.7% vs.10.4%, P=0.03), respectively. We did not find a significant difference in the prevalence of hypertension (27.5% vs. 29.3%, P=0.7) and hypercholesterolemia between the two age groups under study (45.8% vs. 42.9%, P=0.57), but diabetes mellitus was more common in the older age group (15.5% vs. 24.8%, P=0.03). The results indicated that smoking and hypertriglyceridemia were more common among MI patients aged less than 45 years compared to the above-45-year-old age group. Thus, the implications of these findings are to apply further intervention programs for the prevention of risk factors in young adults.

Heart diseases, among them chronic atherosclerotic disease, are recognized as the most prevalent reasons of death in most countries, especially in Iran. For almost half a century now, coronary artery bypass graft surgery (CABG) has helped the medical community combat this disease. However, a considerable number of patients will require repeat grafting (redo surgery) after a variable period of time. The aim of this research was to study redo CABG surgery clinically in patients admitted to a major referral center in Tehran. This retrospective and descriptive study was carried out in light of the medical records of 72 patients who had undergone redo CABG in our department between 1999 and 2002. Patient information was collected via questionnaires concerning demographic data, risk factors, indications for redo operation, ejection fraction, mortality, morbidity and events after redo operation. A statistical analysis, based on the SPSS software, was carried out through a descriptive statistical method. Among the significant findings of this study were a prevalence of 1.72% for redo CABG; reduction in EF (ejection fraction) between the two operations; stable angina as the most prevalent clinical sign; elevation of risk factors such as diabetes, hypertension and hyperlipidemia; short time intervals between the two operations in our country in comparison to the other fully accredited centers abroad; increase in preoperative morbidity; and considerable increase in atherosclerosis in native vessels and implanted grafts. On account of the increase in morbidity and life expectancy of patients, it is suggested that special centers undertake necessary training required to perform redo CABG. The fact that more comprehensive studies are required and that the number of redo CABG is bound to increase necessitates the establishment of more self-sufficient hospitals.

The rapamycin-eluting stent evaluated at RESEARCH registry, reported a 30-day major adverse cardiac event rate of 6.1%. The aim of this study was to evaluate immediate and short-term results (6-9 months) of elective coronary stenting with the non-polymeric rapamycin-eluting Yukon stent in patients with coronary artery disease. In this non-randomized cross-sectional study, 96 patients with stable angina and unstable angina with at least one coronary lesion greater than 50% of luminal diameter by angiographic study were investigated. The subjects were treated with aspirin, c1opidogrel and heparin. Stinting was performed in native coronary vessels with all types of lesions; A, Band C. Overall 110 stents were deployed, with 56 stents in LAD and 29 stents in LCX and 25 stents in RCA lesions. Coronary lesions were 16% type A, 43% B1, 25% B2 and 16%type C lesions.From 96 patients, only 25 patients with 28 stents were re-evaluated 6-9 months after stenting by coronary angiography based on symptom, positive stress test or event. The remaining patients did not refer and refused repeat evaluation due to lack of symptoms. Data were collected in SPSS 10 and analyzed by of T-test, Fisher-exact and Chi squares statistical tests. 96 patients with mean age of 56 years old, 30% female and 70% male, were studied. Coronary risk factor evaluation in patients showed prevalence of 35% for cigarette smoking, 61% hyperlipidemia, 46% hypertension and 20% diabetes mellitus. 5% of patients had history of CABG surgery and 25% had unstable angina. There was no major cardiac event in the first 48 hours and first 30 days after coronary stenting. In-stent restenosis of greater than 50% in 12% of lesions and in-segment restenosis greater than 50% were seen in 16% of lesions. The most important risk factors for restenosis were diabetes mellitus and stent length. Results of this study showed acceptable results of coronary stenting with the rapamaycin- eluting stent, Yukon. The most important risk factors for restenosis were diabetes mellitus and stent length.

An aggressive resection in complex left ventricular tract obstruction (LVOTO) may injure the conduction system and create a ventricular septal defect (VSD). On the other hand, incomplete resection results in residual gradient across the aortic valve. In addition, aortic valve replacement (AVR) in the small aortic root may be impossible or associated with stenosis of the left ventricular outflow tract. The purpose of this article was to evaluate the early and mid-term results of the Rastan-Konno aortoventriculoplasty to address these problems. Retrospective analysis of pertinent data for all the patients who underwent the Rastan- Konno procedure between 1997 and 2003 at our department was performed. Twenty-four patients aged 5-31 years (mean 13.2±7) underwent the Rastan-Konno procedure for severe LVOT obstruction (15 cases) and enlargement of small aortic root (9 cases). The patients had previously undergone LVOT resection (n=6), surgical valvotomy (n=6), AVR (N=2) and balloon valvuloplasty (n=6). The mean preoperative peak systolic gradient across the LVOT was 90.5±34.8 mmHg (range 30-150), which was reduced to 28.1±17.7 mmHg (range 0-66), postoperatively (p<0.001). Permanent heart block developed in 3 patients (12.5%), and a small residual VSD was seen in one patient. There were no cases of prosthetic valve malfunction, permanent paravalvular leak or acute mediastinitis. Hospital mortality rate was 12.5%. One of the patients died due to low cardiac output syndrome, and another patient died following excessive generalized mediastinal bleeding. The third mortality was after a cerebrovascular accident on the 7th postoperative day. There were no deaths during the follow-up (mean 22.6±14.3 months).
Recurrent LVOT obstruction is common after the resection of simple LVOT obstruction; in complex forms, a satisfactory reduction of LVOT gradient is more difficult with only myotomy or myomectomy. The Rastan-Konno aortoventriculoplasty can effectively relieve complex and recurrent LVOT obstruction with minimal morbidity and acceptable mortality rate. In addition, we believe that this procedure can be of benefit for AVR in patients with a small aortic root.

Enhanced external counter pulsation is a novel, potentially beneficial adjunctive therapy used for angina pectoris. We assessed the efficacy of this method in relieving angina and improving objective measures of myocardial ischemia. All the patients (67) who were referred for EECP to our department from 2002 through 2005 were included. Demographic data, CAD risk factors and baseline angiographic data were collected. Anginal symptoms, CCS functional class, echocardiography parameters (EF, LVESD, LVEDD) and exercise test duration before and after treatment were compared. 77% of the patients who had undergone EECP had a positive clinical response. Exercise test duration and CCS functional class improved after the treatment. However, EECP had no significant effect on echocardiographic parameters. Efficacy was independent of age, gender, CAD risk factors, prior CCS functional class, echocardiographic parameters and baseline angiographic data. The patients without left main artery involvement demonstrated a greater likelihood of improvement. The results of this study suggested that EECP is a safe, well-tolerated and significantly effective treatment for angina pectoris.

The relationship between microalbuminuria and coronary events has been established. In the case of retinopathy; however, the issue is controversial. The aim of this study was to determine the relationship between diabetic retinopathy and myocardial infarction as a major presentation of CAD. 180 diabetic patients with and without myocardial infarction were studied in this analytical case-control study. Each group consisted of 38 females and 52 males with a mean age (SD) of 58.27 (11.38) years in the case group and 56.85 (11.11) years in the control group. The two groups were matched except for history of myocardial infarction. SPSS analysis of the data showed no significant differences between the two groups in terms of age and duration of diabetes (DM) [10.34 (8.17) years in the case vs. 10.54 (8.22) years in control group]. There was a significant relationship between the severity of retinopathy and duration of DM (p=0.05), but no significant relation between sex and retinopathy severity was obtained (p=0.1 in case vs. p=0.3 in control group). Although no significant difference between the two groups in terms of the severity of retinopathy (p=0.5) was detected, in the subgroup of the diabetic patients with MI and less than 5 years' duration of DM, retinopathy was more common (p=0.05). Premature retinopathy can predict coronary events. Immediate CAD screening of all diabetic patients with retinopathy is recommended.

This study was performed to define the risk factors of young patients (£45 years old) who presented to our department with an acute myocardial infarction (MI). This case-control study was conducted over a 3-year period from March 2002 to April 2005 in a hospital admitting unselected patients with non-fatal acute myocardial infarction. Risk factor assessment was done in 72 subjects aged ≤45 years with a first acute myocardial infarct and in 143 age and sex-matched population-based controls. The mean (SD) age of the subjects was 40.11 (5.43) years, and 68 (84.5%) were male. In all, 70 subjects (32.55%) were current smokers: 43 (59.72%) in the case group and 27 (19.00%) in the control group (OR: 6.37, CI: 3.24-12.6, P=0.0001). Regular exercise had an independently protective effect on acute myocardial infarction in our young patients (OR: 0.24, 95% Cl: 0.08 to 0.70). Diabetes (OR: 7.66, CI: 2.2-29.15, p=0.0001) was associated with a higher risk of acute myocardial infarction in young adults, but the differences between hypertension (p=0.197), familial history of premature coronary artery disease (CAD) (p=0.25) and body mass index (BMI) (p=0.11) were not significant. According to the results of this study, smoking is a leading risk factor for early acute myocardial infarction in our young patients in the Kurdistan province, which was modulated with primary prevention.

Whether or not atherosclerosis is an infectious disease is not clear. In addition to the classic risk factors, a number of infectious agents such as Chlamydiapneumoniae have been implicated as a possible cause of atherosclerosis. The aim of this study was to determine the presence of C. pneumoniae DNA in atherosclerotic plaques by PCR. Thirty patients (mean age 59±8; 18 male, 12 female) undergoing coronary bypass grafting were included in the study. C. pneumoniae DNA was found in 16 (53%) out of the 30 specimens having been dissected from the subjects' coronary arteries. The presence of C. pneumoniae DNA in a considerable number of these plaques supports the notion that it may have a role in the development of atherosclerosis. The results of studies seeking to clarify the nature of the link between infection and coronary heart disease are eagerly awaited.

Glucocorticoid treatment in babies to prevent chronic long disease causes myocardial hypertrophy and increased myocardial protein content. Although these changes are thought to be transient, there is evidence that dexamethasone (DEX) induces permanent myocardial abnormalities as well. In this study, we investigated the ultrastructural changes of cardiomyocytes during the early period of DEX treatment. Pup rats (age: 5 days, number: 24) were treated with intraperitoneal injection of DEX at doses of 0.5, 0.3 and 0.1mg/kg). Control pups were treated with saline. At 1, 3 and 7 days after injection, the rats were killed. The anatomical parameters were body weight (BW) and heart weight (HW). Our data showed a significant decrease of body weight and heart weight in the 3 and 7-day experimental groups after the last injection. Histological study showed the presence of condensed cardiocytes. Ultrastructural studies showed evidence of degenerative changes in mitochondria and myofibrils and chromatin clumping after the 1st day of DEX injection. In the 3 and 7-day experimental groups, these changes were more serious, and chromatin condensation of cardiomyocytes occurred. Our study showed that neonatal DEX treatment in rat pups causes a decrease in body weight and heart weight during the early period of injection. Histological studies revealed degenerative changes of cardiomyocytes in the experimental pup rats. Ultrastructural studies showed that the type of cell death may be apoptosis.

Mediastinal paragangliomas (pheochromocytomas) are rare tumors representing less than 1% of all mediastinal tumors and less than 2% of all pheochromocytomas. We describe a 53-year-old man successfully operated upon for concomitant coronary artery disease and mediastinal paraganglioma.This is the first report of concomitant surgery for ischemic heart disease and paraganglioma in the world.