Iranian Heart Journal
Volume:23 Issue: 3, Summer 2022

Diabetes mellitus is a metabolic disease characterized by hyperglycemia that results from inadequacies in secreting insulin and/or the action of insulin. Increased exposure to particulate matter at high concentrations is associated with increased mortality in heart diseases. This study aimed to evaluate the effects of insulin and crocin on cardiac electrophysiological parameters, blood pressure, and oxidative stress in alloxan-induced diabetic rats exposed to the total suspended particulate (TSP). 

Adult male Wistar rats (n=60) with bodyweight between 200 and 250 g were divided into 10 experimental groups (6 animals per group): control, crocin, diabetic, TSP (5 mg/kg TSP, intratracheal instillation), diabetic-crocin, diabetic-insulin, diabetic-TSP, crocin-TSP, diabetic-TSP-insulin, and diabetic-TSP-crocin. The effects of chronotropic (heart rate), inotropic (QRS voltage), and dromotropic (P-R intervals and QTc intervals) were evaluated with standard bipolar limb lead II. Systolic and diastolic blood pressure measurements were recorded with the tail cuff. Antioxidant and lactate dehydrogenase enzymes were also measured. 

The diabetic groups and groups exposed to TSP experienced a deleterious effect on cardiac electrophysiological parameters and blood pressure, with a significant decrease in the activity of antioxidant enzymes. These changes were improved with crocin and insulin. 

In this work, the protective role of crocin and insulin alone was observed in diabetic groups and groups exposed to TSP by improving the electrophysiological parameters of the heart, blood pressure, and oxidative stress. 

The present study aimed to compare 4 weeks of exercise (EXE) on the plasma levels of angiogenic markers in male and female rats with experimental myocardial infarction (MI).

Forty male and female Wistar rats were randomly and equally divided into 4 groups: male MI, male MI + EXE, female MI, and female MI + EXE. Subcutaneous injection of isoproterenol (150 mg/kg) was used to induce MI. The training groups performed an endurance training protocol on the treadmill for 4 weeks (speed=18 m/min, 30 min, 5 sessions per week). Sacrifice and blood sampling were performed 24 hours after the last training session. The data were analyzed using 2-way ANOVA and LSD post hoc tests.

Vascular endothelial growth factor levels were significantly higher in the female MI + EXE group than in the male MI + EXE group (P=0.037). Changes in matrix metalloproteinase 2 levels were greater in the female rat group than in the male rat group (P=0.017). Matrix metalloproteinase 9 levels were higher in the MI + EXE female rats than in the MI + EXE male rats (P=0.008).

Our findings showed that sports rehabilitation had positive effects on experimental MI, which is likely to cause clinical changes and improve angiogenic parameters in female rats more than in male rats.

A decrease in blood oncotic pressure following hemodilution due to cardiopulmonary bypass (CPB) in cardiac surgery results in fluid shift and organ dysfunction. The present comparative study evaluated the effects of adding albumin and fresh frozen plasma (FFP) to the priming solution of a CPB system on clinical and laboratory outcomes in pediatric congenital cardiac surgery candidates. 

The present clinical trial study recruited 2 groups of 50 pediatric patients (weight<10 kg) scheduled for the elective surgical repair of congenital heart diseases. The study population was randomly assigned to 2 groups: FFP and albumin. The patients’ hemodynamic parameters, diuresis, chest tube drainage, transfusion, and inotropic drugs, as well as laboratory tests, including the erythrocyte sedimentation rate (ESR), C-reactive protein, blood urea nitrogen, creatinine, lactate, hemoglobin, and hematocrit, were measured as the trial’s primary outcome. 

ESR was significantly higher in the FFP group (P<0.05). Blood urea nitrogen and creatinine were remarkably lower in the albumin group (P<0.05). No significant differences in hemodynamic variables, the volume of the red blood cell transfusion, the volume of the inotropic infusion, and clinical outcomes were observed between the 2 groups. 

In patients with FFP in the prime solution, a higher ESR value was observed. While there was no significant difference between the 2 groups regarding hemostasis, albumin offered the advantages of better kidney, liver, and cardiac functions. 

Bleeding and pseudoaneurysm formation are the dangerous complications of the Bentall operation. We made a simple modification to the proximal anastomosis in the Bentall operation to reduce postoperative bleeding and false aneurysm incidence. This article presents a review of the early results. 

Totally, 171 consecutive patients (126 men and 45 women) underwent aortic root replacement between September 2014 and April 2020: as an elective operation in 130 patients (76.02%) and as an emergent or urgent operation in 41 (23.98%). No exclusion criteria were applied. All the Bentall operations during the study period were performed via the same surgical technique. Statistical analysis was conducted with the SPSS 11.0 statistical software package (SPSS, Chicago, IL, USA). Continuous variables were expressed as the mean ± the standard deviation and compared using the unpaired 2-tailed t test, and categorical variables were analyzed using the χ2 test or the Fisher exact test, where appropriate. 

The mean duration of cardiopulmonary bypass was 88.30 minutes, and the mean duration of aortic clamping was 53.17 minutes. Reoperation was required due to postoperative bleeding in 14 cases (8.19%). The early mortality rate was 8.77%, and the incidence of complications was 15.19%. 

Our simple modification, which was the addition of a protection layer, to the standard technique of the Bentall operation did not significantly increase the duration of cardiopulmonary bypass, and it seemed to have caused a significant decrease in bleeding after surgery and the need for reoperation. 

The idea of preoperative overnight fasting was challenged and verified to have no benefits compared with drinking clear liquids up until 2 hours before surgery. In this study, we explored the possible effects of preoperative oral carbohydrate loading (OCL) on insulin resistance and the clinical outcomes of patients undergoing cardiac surgery. 

Totally, 260 patients were recruited and allocated randomly to intervention (n=130) and control (n=130) groups. The intervention group received 250 mL of an oral carbohydrate fluid containing 25 g of glucose, and the control group received standard care. Insulin resistance, glycemic indices, and clinical outcomes were assessed before and after surgery. 

Totally, 107 patients in the intervention group and 103 in the control group completed the study and were, thus, included in the final analysis. Preoperative OCL 2 hours before surgery improved postoperative fasting blood sugar and clinical outcomes after cardiac surgery including thirst, hunger, anxiety, pain, the length of stay in the hospital, and the length of stay in the ICU (all Ps<0.05). 

OCL administered preoperatively seems to be beneficial in improving the biochemical and clinical outcomes of patients undergoing cardiac surgery. Notably, preoperative OCL as a safe, simple, and cost-benefit approach is associated with no or negligible harm and, therefore, could be recommended in the setting of cardiac surgery, with careful attention to contraindications. 

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Rhythm control is a treatment option. Ablation is done via 2 different

radiofrequency (RF) ablation and cryoballoon ablation. An evaluation of the outcome of these methods in a tertiary center is necessary. Methods This historical cohort study recruited 299 patients undergoing ablation. RF was performed on 150 patients, while 149 underwent cryoballoon ablation. Age, sex, risk factors (diabetes mellitus, hypertension, and renal failure), symptoms (palpitations, dyspnea, bradycardia, dizziness, and chest pain), echocardiography data, and complications were extracted from documents. Baseline characteristics and outcomes were compared between the 2 groups.

All baseline characteristics were comparable between the 2 groups, except age (P=0.029), renal failure (P=0.018), and the left ventricular ejection fraction (P=0.011), which were higher in the cryoballoon group. The overall complication rate was higher in the RF group (P=0.021), but the 2 groups were comparable concerning each complication. Recurrence within less than 1 month was higher in the cryoballoon group (P=0.002).

Both RF and cryoballoon methods have their advantages and disadvantages. A historical cohort study to compare the outcomes between these 2 methods is not the proper choice in that it fails to determine which procedure confers a better outcome. A prospective survey seems more suitable for this evaluation. 

Heart transplantation is the last therapeutic choice in patients with severe heart failure who are symptomatic despite medical treatments and are estimated to have less than a year to live. Given the dearth of information on the initial years and outcomes of heart transplantation, we conducted the present study to determine the results of this procedure at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, since the first transplantation. 

The current observational study, performed as a retrospective cohort, recruited 50 consecutive children who underwent heart transplantation between March 2014 and April 2017 in a census manner and determined their outcomes. 

Renal failure before transplantation was reported in 3 patients (6%), of whom 2 patients (4%) required dialysis. After transplantation, 11 subjects required dialysis. Eight patients (16%) developed hepatic failure before transplantation. Infectious complications were seen in 14 patients (28%) after transplantation. Nine patients (18%) had 1 rejection time. The mortality rate was 6%. 

It seems that despite similar indications for heart transplantation in different centers, our study revealed better results than previous studies. However, the technical and skill differences between physicians in various settings should be considered possible explanations. 

Anti-annexin A5 antibodies (aANVAs) are thought to have the capacity to cause thrombosis and to be a risk factor for cardiovascular diseases. The present study aimed to detect changes in aANVAs in acute myocardial infarction (AMI) on admission and 10, 40, and 70 days after the acute phase.

Forty-five patients with confirmed AMI were selected for analysis. Plasma aANVAs were measured by enzyme-linked immunosorbent assay (ELISA) on admission and 10, 40, and 70 days after AMI.

Significant positive cases of aANVAs were observed during the follow-up (P<0.001). The positive cases of aANVAs were more during a 70-day period than on admission (P=0.004) and 10 days (P=0.008) and 40 days (P=0.016) following AMI. No significant increase was found in the plasma concentration of aANVAs during the follow-up (P>0.05).

A significant increase was observed in aANVAs-positive cases on the 70th post-AMI day. The increase may indicate the existence of a hyperactive coagulopathy state during this period. 

Patients with a prolonged corrected QT (QTc) interval are at risk of arrhythmias, including Torsade de pointes (TdP). This interval could be affected by demographic characteristics, ischemia, and most importantly drugs. Furthermore, hospitalized patients tend to experience arrhythmias, accompanied by electrolyte abnormalities and the inflammatory status of diseases.

The present retrospective study recruited 135 patients with COVID-19. We observed the QTc interval on the third post-administration day and laboratory findings for possible risk factors for QTc-interval prolongation.

Ischemic heart disease was markedly more common among patients with prolonged and severely prolonged QTc intervals. Laboratory findings showed a significantly higher neutrophil-to-lymphocyte ratio (NLR) in patients with prolonged or severely prolonged QTc intervals compared with those with normal QTc intervals and QTc intervals exceeding 500 milliseconds (P<0.001) on admission and the third day. Ribavirin caused the most elevation in the QTc interval after 3 days of hospitalization compared with other drugs. Forty percent of the patients who took ribavirin experienced a QTc interval exceeding 500 milliseconds, which was significant compared with other therapeutic regimens.

In addition to the well-known predisposing factors for the prolongation of QTc interval, we suggest focusing on the history of ischemic heart disease and inflammatory status (eg, by NLR) in patients with COVID-19 before making decisions to commence drugs that greatly affect QTc intervals. Further studies are required to shed light on the cardiac side effects of medications applied for COVID-19, particularly ribavirin. 

Inherited hemoglobin disorders such as thalassemia are among the most critical public health concerns. Heart failure (HF) is one of the essential complications in β-thalassemia patients. Cardiac iron accumulation is the single greatest risk factor for cardiac dysfunction in thalassemia. Our study aimed to determine factors associated with HF in β-thalassemia patients.

This was a retrospective cohort study on 2913 patients with thalassemia. Thorough medical history taking and physical examinations were done for a basic cardiac assessment, including 12-lead electrocardiography and detailed echocardiography, according to the guidelines. Cardiac magnetic resonance imaging was used to evaluate cardiac iron overload (T2), which was an invaluable tool to estimate the clinical risk and the development of heart complications in the patients. A logistic regression model was used in SPSS, version 23.0, to assess HF factors. The Hosmer–Lemeshow test and ROC curve were used for goodness of fit.

Overall, 14.69% of the patients had HF. The logistic regression model showed that thalassemia major, older age, higher hemoglobin, higher ferritin, later initiation, iron chelators, more blood transfusion, and comorbidities increased the risk of HF in thalassemia patients. The adjusted area under the ROC curve in the logistic regression model was 0.79.

Most factors related to an increased risk of HF in thalassemia patients were controllable. The timely onset of transfusions and iron chelator therapy, as well as long-life follow-up, can help detect cardiac involvement and treat the disease early. 

The target-controlled infusion (TCI) system controls the plasma concentration of administered drugs, improves hemodynamic stability, prevents the cumulative effect of drugs, provides faster recovery, and perhaps reduces renal complications. We sought to investigate the effects of the TCI method on blood urea nitrogen (BUN) and creatinine (Cr) levels in patients with renal impairment undergoing open-heart surgeries.

This double-blind clinical trial was performed on 66 patients undergoing cardiac surgeries with preoperative Cr levels of greater than 1.5 mg/dL. The patients were randomly divided into 3 groups. The first group received propofol and remifentanil via the TCI system. The second group received these 3 drugs via the usual dosing (mg/kg) method. The third group received midazolam and fentanyl conventionally (based on the mg/kg method). Postoperative Cr and BUN levels, urine volume, the need for dialysis, and hemodynamic parameters were recorded up to 3 postoperative days. After the exclusion of 10 patients from the study, 56 patients were analyzed.

Postoperative BUN and Cr values were significantly lower in the TCI group than in the other groups (P<0.05) There were no significant differences between the 3 groups concerning hemodynamic status. The total dose of anesthetics was significantly lower in the TCI group than in the propofol-remifentanil group (P<0.05). The incidence of postoperative arrhythmias in the TCI group was significantly lower than that in the other 2 groups (P<0.05).

In our patients with renal dysfunction, the TCI method reduced post-cardiac surgery BUN and Cr levels, the dose of the anesthetics administered, and the incidence of arrhythmias. 

Dipyridamole is administered as a substitute for physical activity during myocardial perfusion imaging (MPI). The purpose of this work was to evaluate the correlation between any kind of electrocardiogram (ECG) arrhythmia induced by dipyridamole and MPI findings in single-photon emission computed tomography (SPECT) imaging.

This study included 759 patients referred to the Nuclear Medicine Department of Hazrat Rasoul Akram Hospital. The study population underwent the dipyridamole MPI SPECT protocol. ECG for all the patients before and during dipyridamole infusion was obtained and assessed by cardiologists. All the patients underwent stress-rest technetium (99mTc) sestamibi-gated SPECT imaging using a 2D protocol.

ST depression and ST elevation were observed in 69 (9.1%) and 23 (3%) patients, respectively, which had significant relationships with the moderate/high-risk stratification outcomes of MPI. Atrioventricular block, premature ventricular contractions, paroxysmal supraventricular tachycardia, bradyarrhythmia, and tachycardia showed no significant associations with moderate or high levels of risk stratification in MPI, and they were seen in 34 (4.5%), 34 (4.5%), 24 (3.2%), 16 (2.1%), and 39 (5.1%) patients, respectively.

High-risk MPI scan patterns had a significant correlation with ST depression and a relatively appraisable correlation with ST elevation in dipyridamole-induced ECG arrhythmia.

Aortopulmonary window (APW) is a rare congenital cardiac condition resulting in a communication between the aorta and the pulmonary artery. APW can occur as a single lesion or may be associated with other cardiac defects such as ventricular septal defects, atrial septal defects, and tetralogy of Fallot. More than 50% of APW cases are associated with other additional congenital cardiac defects that require surgery. Most patients can develop congestive heart failure at an early age due to left-to-right shunts. The patient survival rate with untreated APW is very low, with a mortality rate of 40% in the first year. Survival into adulthood without treatment is very uncommon. We herein describe a 62-year-old man with Eisenmengerized APW with acquired severe aortic stenosis, mild pulmonary valvular stenosis, and Ortner syndrome without surgery. Ortner syndrome is mainly caused by the compression of the recurrent laryngeal nerve due to the dilatation of the pulmonary artery and the aorta. 

A 44-year-old woman presenting with a typical history of acute coronary syndrome and anterolateral myocardial infarction in electrocardiography underwent primary percutaneous coronary intervention (PCI). After a few days, she complained of motor and sensory loss in her lower extremities. Given her symptoms, signs, and laboratory exams, Guillain–Barre syndrome (GBS) was diagnosed. Her management was done successfully with therapeutic plasma exchange. Acute myocardial infarction and subsequent PCI might be one of the most uncommon reasons for GBS. 

A left atrial appendage aneurysm (LAAA) is an extremely rare anomaly commonly diagnosed incidentally or following thromboembolic or tachyarrhythmia occurrence. LAAAs can lead to life-threatening adverse events such as atrial fibrillation, myocardial infarction, and systemic thromboembolism. We herein report an LAAA in a 35-year-old man presenting with episodes of chest discomfort and sudden-onset palpitations, along with exertional dyspnea. He underwent an aneurysmectomy with cardiopulmonary bypass. 

Myxomas, though uncommon in the general population, comprise the most common cardiac tumors. The majority of these tumors are located in the left atrium (75%), followed by the right atrium (20%), the right ventricle (8%), and the left ventricle (3%–4%). Less common forms involve all cardiac chambers, pulmonary vessels, and mitral and aortic valves. Cardiac myxomas arising from the superior vena cava (SVC) constitute an extremely rare presentation of these tumors. The involvement of the SVC in cardiac myxomas is generally secondary to expansion from the right atrium; nonetheless, an SVC origin with the secondary involvement of the right atrium is extremely rare. Herein, we describe a young man presenting with syncope. Further evaluations revealed a mass originating from the SVC with myxoma pathology.

Right-sided heart failure may occur during or after cardiac and noncardiac surgeries. One reason for right-sided heart failure in noncardiac surgeries is pulmonary hypertension (PH). In this report, we describe a 51-year-old man suffering from complications of right-sided heart failure, with an unknown cause. The patient had dyspnea (WHO functional class III), abdominal pain, anorexia, weight loss, bilateral lower limb swelling, icteric sclera, and elevated jugular venous pressure. Echocardiography showed mild enlargement and systolic dysfunction of the left ventricle, moderate enlargement and dysfunction of the right ventricle, and a systolic pulmonary arterial pressure of 60 mm Hg. After several workups, it was diagnosed that his previous lumbar disc surgery had resulted in an arteriovenous fistula and the consequent PH, leading to right-sided heart failure. After the occlusion of the arteriovenous fistula, all signs and symptoms were resolved. Accordingly, iatrogenic arteriovenous fistulae should be considered a reversible cause of right-sided heart failure.

We herein describe 2 neonates with cyanotic-type congenital heart disease and COVID-19. The first case was a boy at 37 weeks of gestational age (GA) who had cyanosis (SpO2 <90%) on the second day of the birth. He was transferred to the neonatal intensive care unit (NICU) for COVID-19 patients for infection treatment following a positive COVID-19 PCR test. Finally, he had a cardiopulmonary arrest, and cardiopulmonary resuscitation failed. The second case was a boy at 38 weeks of GA. His fetal echocardiography showed a hypoplastic right ventricle with decreased contractility, an atretic tricuspid valve, a hypoplastic pulmonary valve, and a small echogenic focus in the left ventricle. He was then diagnosed with COVID-19 and treated with Kaletra. Follow-up echocardiography showed a functioning shunt, a relieved pericardial effusion, and a normal ejection fraction. He was discharged a week later in good general condition. 

Some degrees of hemolysis are probable in pediatric patients receiving cardiopulmonary bypass. Nonetheless, severe hemolysis, even in premature infants undergoing cardiac surgeries, is rare. When hemolysis happens in a neonate or infant receiving cardiopulmonary bypass, numerous causes, including erythrocyte membrane defects, hemoglobinopathies, iso-immunization, undiagnosed enzyme abnormalities, and acquired conditions such as sepsis or drug interactions, should be considered. Urine discoloration may be considered a hemolytic reaction secondary to blood transfusion; still, in mild degrees of hemolysis due to mechanical trauma, this discoloration may not be noticed. One type of acute hemolytic reaction is immunological, which may happen secondary to the interaction between the recipient’s antibodies and the donor’s antigens, although most severe cases of hemolytic anemia are secondary to ABO incompatibility In this case report, we describe a 15-month-old infant undergoing surgical repair for tetralogy of Fallot, who developed hemolysis during cardiopulmonary bypass. We also discuss the case’s diagnostic workup and therapeutic management.