Iranian Heart Journal
Volume:24 Issue: 2, Spring 2023

Epinephrine, norepinephrine, and phenylephrine may have different effects on cerebral O2 saturation when used to treat intraoperative hypotension. The present study aimed to evaluate these effects on cerebral O2 saturation in patients undergoing cardiopulmonary bypass (CPB) during heart surgeries.

The current randomized clinical trial enrolled 114 adult patients, 90 of whom were eligible for randomization into 3 groups (each=30) receiving epinephrine, norepinephrine, and phenylephrine if they experienced hypotension (mean arterial pressure [MAP]<60 mm Hg) during surgery. Cerebral oximetry as the primary outcome, hemodynamic parameters, consisting of heart rate, MAP, and arterial blood gas (ABG), and lactate levels were recorded prior to surgery and 120, 150, and 180 seconds after vasopressor administration during CPB.

The 3 study groups were similar regarding demographic variables. Hemodynamic parameters, including ABG, and lactate levels showed no statistically significant differences between the groups (P>0.05). Additionally, cerebral O2 saturation at baseline and 120, 150, and 180 seconds after vasopressor administration was not statistically different between the 3 groups (P>0.05).

The administration of epinephrine, norepinephrine, or phenylephrine in adult patients undergoing cardiac surgery with CPB support yielded no statistically significant differences in clinical and hemodynamic parameters.

Malnutrition is a common condition related to poor prognosis in patients with heart failure (HF). The present study aimed to investigate the impacts of nutritional indices on short-term clinical outcomes and elucidate risk factors associated with the need for nutritional supplementation in patients with acute decompensated heart failure (ADHF).

To evaluate the nutrition index at the beginning of hospitalization, we completed the Mini Nutritional Assessment (MNA) questionnaire and calculated the Nutritional Risk Index (NRI) and the Controlling Nutritional Status (CONUT) score in patients with ADHF.

Over 40% of hospitalized patients with ADHF had moderate-to-severe nutritional disturbances determined by the NRI, the MNA, and the CONUT score. During a 1-month follow-up, hospitalization was reported in 8 patients, of whom 3 died.  Twenty-five of 58 patients (43%) were categorized as needing nutritional support. Lower body mass indices and total albumin levels were independent predictors of the need for nutritional support (OR, 0.35; 95% CI, 0.13 to 0.97; P=0.044 and OR, 0.36; 95% CI, 0.15 to 0.88; P=0250, respectively).

Over 40% of hospitalized patients with ADHF had moderate-to-severe nutritional disturbances and needed nutritional support. The assessment of nutritional status may provide additional prognostic information and, thus, could be useful in the risk stratification of patients with ADHF.

Diagnosis and early treatment of the cardiac causes of chest pain are of particular importance. This study aimed to investigate the association between NT-pro-BNP levels as a cardiac marker and the prognosis of patients with chest pain.

All patients visiting the emergency department of a tertiary cardiovascular center with chest pain between October 2016 and March 2017 were evaluated for eligibility. Demographic data, proBNP levels, final diagnosis on angiography, echocardiography, and other symptoms were recorded.

A total of 222 patients at a mean age of 59.0±14.8 years were studied. Totally, 127 patients (57.2%) were male. A significant inverse relationship was found between proBNP levels and the left ventricular ejection fraction (r= -0.316; P<0.001). NT-proBNP levels showed a significant elevation in patients with abnormal size and function of the right ventricle, with regional wall motion abnormalities, and with valvular heart diseases (P<0.05). The BNP level in patients with abnormal angiographic results was 1148.5 (405.3–3214.0), significantly higher than that in patients with normal results (545.0: 90.3–2807.8; P=0.009). The level of this marker in patients with obstructive coronary artery disease (1192.0: 438.8–3233.0) was significantly higher than that in patients with non-obstructive coronary artery disease (620.0: 108.0–2792.0; P=0.001). BNP>841 pg/mL had a sensitivity of 92.9% and a specificity of 47.9% in identifying cases at risk of complications.

NT-proBNP could be a good diagnostic and prognostic marker for patients with chest pain complaints. Measuring this marker upon arrival can help identify patients with cardiac diseases. It is recommended to evaluate patients with elevated levels of this marker for earlier diagnosis and treatment. 

Postoperative pulmonary complications (PPCs) are among the leading causes of morbidity, mortality, and increased length of stay (LOS).

In a prospective cohort study, all adult candidates for all types of open-heart surgeries were enrolled and followed from admission to discharge for PPCs.

The study population consisted of 918 consecutive adult patients, including 574 (62.5%) males, at a mean age of 56.20±13.95 (mean ± standard deviation) years who underwent open cardiac surgery. Among them, 537 patients (58.5%) suffered PPCs, comprising pleural effusion in 293/916 (32.0%), atelectasis in 222 (24.2%), pneumonia in 68 (7.4%), diaphragm paralysis in 67 (7.3%), pulmonary edema and/or acute respiratory distress syndrome in 64/915 (7.0%), pneumothorax (in the right or left hemithorax) in 28/916 (3.1%), hemothorax in 7/915 (0.8%), subcutaneous emphysema in 11/913 (1.2%), and empyema in 2/918 (0.2) The independent risk factors for PPCs were age (OR, 1.010; 95% CI, 1.001 to 1.020; P=0.0326), female sex (OR, 1.375; 95% CI, 1.044 to 1.811; P=0.0235), and renal dysfunction (OR, 1.553; 95% CI, 1.001 to 2.409; P=0.0497). Twenty-three patients died within 30 days of cardiac surgery, accounting for a hospital mortality rate of 2.5%.

The cumulative incidence rate of PPCs was 58.5% in our center, with a mortality rate of 3.4%. The overall mortality rate among all the patients was 2.5%. The independent risk factors associated with PPCs were age, female sex, and renal failure. 

The present study aimed to investigate the agreement and convergence of left ventricular dyssynchrony parameters extracted from phase analysis using GSPECT images under different conditions of filtration and reconstruction.

The study population included 120 consecutive patients with normal or abnormal GSPECT MPI. All patients underwent a 2-day rest and stress sestamibi GSPECT MPI. The GSPECT images were reconstructed and processed using reconstruction methods including filtered back projection (FBP) with Butterworth (cutoff =0.45, order =5) and Metz (cutoff =0.9, order =6) filters and ordered-subset expectation maximization (OSEM) (subset=4,16; iteration =8) with Gaussian filters. Phase analysis (PA) parameters were evaluated globally and regionally (anterior, inferior, septum, lateral, and apex) in patients with normal MPI and those with abnormal MPI.

According to intraclass correlation (ICC) analysis, there was a significant and robust convergence between the OSEM (4,8) and OSEM (16,8) reconstruction algorithms, both of which were with Gaussian filters (P<0.001). Furthermore, there was a significant and robust convergence between FBP and Butterworth (cutoff =0.45, order =5) and between FBP and Metz (cutoff =0.9, order =6) in measuring PA parameters (P<0.001).

The findings indicated that PA parameter values obtained from GSPECT MPI data with the FBP and OSEM image reconstruction methods were strongly correlated. However, the values of normal patients were dependent on the reconstruction technique. Therefore, reconstruction methods should not be used interchangeably. 

Controversies exist surrounding the advantages and disadvantages of anatomical landmarks (ALs) and ultrasound (US) guidance as 2 methods of central venous catheter (CVC) placement among pediatric patients. The present study compared the success rate and complications of CVC placement in the internal jugular vein between US guidance and traditional AL methods among pediatric patients.

The present open-labeled randomized clinical trial was performed on 120 pediatric patients aged 3 months to 6 years undergoing cardiac surgeries. The patients were randomly allocated to the US-guided and AL groups. After the induction of anesthesia and intubation, the CVC was placed according to the placement method of each trial group. The success rate of first-attempt CVC placements was the primary outcome, while placement time, vein punctures, and arrhythmias constituted the secondary outcomes.

The trial assessed 120 patients (63, 52.5% female). The mean CVC placement time was 204.1±111.7 seconds. The success rate of first-attempt CVC placements was the same in both groups (47/60; 78.33%). The AL group experienced significantly more side effects than the US-guided group (23 arrhythmias [38.33%]   and 5 arterial punctures [8.33%] vs 2 arrhythmias [3.33%] and 3 arterial punctures [5%]; P<0.001).

The complication rate of CVC placement in the US-guided group was lower than that in the AL group; thus, the former method can be considered safer in pediatric patients. 

Atrioventricular nodal reentry tachycardia (AVNRT) is the most common type of supraventricular tachycardia, and catheter slow pathway ablation is the first-line therapy in this arrhythmia. The endpoint for the successful ablation of AVNRT is the noninducibility of the tachycardia rather than the complete ablation or modification/ablation of slow pathways. We aimed to compare heart rate variability (HRV) parameters between slow pathway complete ablation and slow pathway modification/ablation for AVNRT.

The current study enrolled 78 eligible patients with AVNRT. Slow pathway complete ablation was performed on 49 patients, and 29 patients underwent slow pathway modification/ablation. HRV parameters on 24-hour Holter monitoring were compared before and 30 days after ablation between these 2 groups.

HRV parameters, consisting of the mean heart rate, the standard deviation of normal-to-normal RR intervals over 24 hours (SDNN), the standard deviation of the average NN intervals for all 5-minute intervals in a 24-hour continuous electrocardiographic recording (SDANN), and a percent NN interval exceeding 50 milliseconds from the prior interval (PNN50), were not significantly different in the group with complete slow pathway ablation. The comparison between pre and post-intervention entities revealed statistically significant differences in SDNN (P=0.041) and PNN50 (P=0.008) in the group with slow pathway modification/ablation. Additionally, PNN50 was significantly lower in the modification/ablation group than in the complete ablation group.

We noted negligible differences regarding HRV-associated indices between the slow pathway complete ablation and modification/ablation for AVNRT groups. 

Despite steps in lifestyle changes and preventive measures, the incidence of heart disease is still rising. Coronary artery disease (CAD) is the world’s leading cause of death; thus, the early detection of this disease can significantly reduce its mortality rate. We evaluated the diagnostic value and prognostic role of positive exercise stress echocardiography in CAD.

The present retrospective study was performed on 350 patients with symptoms of IHD referred for exercise stress echocardiography between 2004 and 2017. The obtained data were analyzed using the SPSS software.

Ischemic electrocardiographic (ECG) changes, the regional wall motion abnormality (RWMA) score index, the metabolic equivalent, and the peak left ventricular ejection fraction were associated with CAD (P=0.004, P=0.000, P=0.02, and P=0.000, respectively). The incidence of ventricular arrhythmias was associated with sudden cardiac death and myocardial infarction (P=0.00). Ischemic ECG changes were significantly associated with myocardial infarction and the need for percutaneous coronary interventions in the future (P=0.04 and P=0.03). The relationship between left ventricular dilation and sudden cardiac death was significant (P=0.01), and RWMAs were significantly associated with myocardial infarction (P=0.03). However, dyspnea and chest pain had no association with cardiac events.

Positive exercise stress echocardiography was associated with sudden cardiac death, myocardial infarction, and the need for future coronary revascularization, and its diagnostic and predictive role was observed in ischemic heart disease and predicting future cardiac events. 

Cardioembolic strokes cause more severe disabilities than other subtypes of ischemic strokes. Considering that thrombus formation predominantly occurs in the left atrium (LA), the structure and function of the LA may cause a risk for embolic strokes even in the absence of atrial fibrillation (AF). We hypothesized that functional and structural LA alterations could be associated with acute ischemic strokes regardless of AF occurrence and history.

This comparative cross-sectional study assessed 40 patients with cerebrovascular accidents (CVA) and 40 healthy controls. We included patients aged above 18 years with ischemic CVA within the preceding 6 months and without AF rhythm. Global longitudinal strain (GLS) was calculated using 2D speckle-tracking echocardiography.

Significant differences existed between the 2 groups regarding the mean values of LAA4C GLS (P=0.01), LAA3C GLS (P=0.002), LAA2C GLS (P=0.002), LA TOTAL GLS (P=0.001), LVA4C GLS (P=0.01), and LV TOTAL GLS (P=0.04). Nevertheless, no significant differences existed in the LA area, LA diameter, EF, LVEDV, LVESV, LVA3C GLS, and LVA2C GLS between the groups.

Our findings suggested the possible involvement of LA morphofunctional dysfunction in CVA events in patients with sinus rhythm. 

Arteriovenous fistula (AVF) placement is a surgical procedure performed under local anesthesia and often without the need for muscle relaxants in patients with end-stage renal disease. The results of studies comparing remifentanil (REM) and dexmedetomidine (DEX) in patients undergoing AVF placement are controversial. The present study compared sedation efficacy between REM and DEX in patients undergoing AVF placement.

The present double-blind randomized clinical trial enrolled 40 patients in the operating room of Shahid Hashemi-Nejad Hospital in 2 groups and compared sedation between REM and DEX at different times during and after the surgery using a visual analog scale and the Ramsay score. The data were recorded and analyzed using SPSS, version 22.

The average pain score 120 minutes after the surgery was 4.9±0.72 and 4.3±0.80 in the DEX and REM groups, respectively (P=0.017). No significant difference was observed in the level of sedation between the 2 groups (P=0.113). The prevalence of tachycardia and bradycardia in the 2 groups was 10% (P=1.00) and 15% (P=1.00), respectively, and no significant difference was observed.

We found no significant differences between DEX and REM concerning sedation efficacy. Further studies with larger sample sizes in each group of patients and different procedural scenarios are recommended. 

Left ventricular (LV) non-compaction is a genetic disease which might result in heart failure, arrhythmias, and thromboembolic events. Nonetheless, other diseases and drugs or toxins like chemotherapy agents can also simulate or exacerbate this phenotype and accelerate systolic dysfunction. Moreover, cancer and receiving chemotherapy agents are procoagulant states leading to venous, arterial, and intracardiac thromboses.

Case: 

A 62-year-old man with a history of lung squamous cell carcinoma from 4 months earlier and non-compacted LV presented with dyspnea, severe LV systolic dysfunction, and multiple large LV clots.

Non-compacted LV can be a risk factor to exacerbate the cardiotoxicity of cancer therapeutics and lead to severe LV systolic failure. Additionally, severe LV systolic dysfunction, advanced stages of the lung cancer, the hypercoagulable state of cancer, and chemotherapy drugs like platinum agents could result in the formation of multiple large clots in the LV. 

Air embolism is a complication of electrophysiological procedures, including atrial fibrillation (AF) ablation. Despite the benign course of air embolism in most patients, it can be a life-threatening event due to systemic air embolism to the coronary or brain circulation. Interruption of blood to vital organs may lead to serious damage.

Case:

 A 77-year-old woman with a history of AF in the preceding 8 years was a candidate for AF ablation due to symptomatic persistent AF following the discontinuation of flecainide. Massive air embolism during catheter ablation developed in the left atrial appendage (LAA). Aspiration with a pigtail catheter through the trans-septal sheath was not successful, but the air was evacuated using the Judkins right catheter without any permanent complications.

An operator must be au fait with all technical aspects of air embolism management. End-hole catheters may be more effective for the aspiration of aeroembolism in the LAA than multi-orifice pigtail catheters. 

Heparin is widely used in patients undergoing cardiac surgeries on cardiopulmonary bypass; however, it can cause some complications, mainly including bleeding and thrombocytopenia. Heparin-induced hyperkalemia is a rare and less recognized adverse effect of heparin therapy that can lead to serious morbidities. Herein, we describe a 69-year-old Caucasian woman with coronary artery disease who underwent coronary artery bypass graft surgery. The postoperative electrocardiogram was normal without any signs of ischemia or arrhythmia. After the patient was transferred to the intensive care unit, her potassium level was 5.8 mEq/L, which remained high. She had not perioperatively received any causative agent of hyperkalemia. All laboratory tests were within normal ranges. Despite adequate diuresis, a relatively steady state of renal function, and hyperkalemia treatment, including intravenous glucose and furosemide and insulin infusion, the patient’s potassium level increased progressively. All etiologies of hyperkalemia were ruled out, and consequently heparin-induced hyperkalemia was suspected.

Myocarditis accompanied by a high-grade atrioventricular (AV) block is a rare manifestation of COVID-19 infection. A 53-year-old woman presented with an episode of syncope, dyspnea, dry cough, and fever. On physical examination, the patient had high blood pressure and bradycardia. Her electrocardiography displayed a complete AV block with a junctional escape rhythm. Laboratory investigations revealed leukocytosis, elevated D-dimer, a positive SARS-CoV-2 nasopharyngeal swab, and a significant elevation in troponin. No reversible cause of the AV block was found, and the complete AV block persisted after the complete treatment of COVID-19. A His bundle permanent pacemaker was then implanted. An endomyocardial biopsy demonstrated endomyocardial tissue with focal hemorrhage, fatty infiltration in the endocardium, and active chronic inflammation, supporting the diagnosis of myocarditis. Several hypotheses of complete heart block in COVID-19 infection have been proposed, including direct myocardial injury and enhanced inflammatory response. A persistent total AV block following complete COVID-19 treatment is an indication for permanent pacemaker implantation. 

Turner Syndrome occurs when one of the X chromosomes is missing, either partially or completely. Heart defects associated with some cases of Turner syndrome can increase the risk of severe, life-threatening complications, including pulmonary hypertension and aortic dissection. A 35-year-old woman, a known case of Turner syndrome, presented with acute dissection in the ascending aorta (Type A Stanford). The patient had a successful aortic valve repair surgery with a Dacron tube graft interposition. The risk of aortic dissection in Turner syndrome is 100 times greater than that in the general population. Diagnosis was made by transthoracic echocardiography and computed tomography angiography. Due to the small size of the femoral artery, cannulation was done in the innominate artery. Cardiopulmonary bypass was established, and systemic cooling was initiated to a temperature of 25 ℃. The patient was discharged from the hospital in good condition.