Iranian Heart Journal
Volume:24 Issue: 3, Summer 2023

The solutions used to prepare the cardiopulmonary bypass (CPB) circuit are known to constitute some of the potential causes of metabolic acidosis at the onset of CPB. Solutions containing lactate, acetate, and other anions have a buffering effect owing to the metabolism of these anions into bicarbonate ions. Hence, the administration of lactate-containing solutions to children may lead to elevated serum lactate levels.
 
The present double-blind randomized clinical trial evaluated 50 non-cyanotic pediatric patients (2 groups of 25 cases) aged between 12 and 48 months undergoing cardiac surgeries. Ringer’s solution and Ringer’s lactate solution were each used in 1 study group as the CPB prime solution. The levels of pH, bicarbonate, base excess (BE), lactate, calcium, glucose, chloride, and arterial blood gas were measured at 4 different time points: before the initiation of CPB (T0) and then 5 (T1), 30 (T2), and 60 (T3) minutes after bypass commencement.
 
The levels of pH at T1 and T2 were statistically different between the 2 groups (P=0.029 and P=0.001, respectively). The 2 groups were also statistically meaningfully different concerning T2 BE (P<0.0001). The mean HCO−3 levels at T2 and T3 were statistically different between the groups (P<0.0001 and P=0.039, respectively). Lactate levels at T1 and T2 statistically significantly differed between the 2 groups (P<0.0001 and P=0.017, respectively).
 
The current study showed that Ringer’s lactate solution as the CPB prime solution was more effective than Ringer’s solution in reducing CPB-induced acidosis without increasing the circulatory lactate level. (Iranian Heart Journal 2023; 24(3): 6-14)

Noninvasive diagnostic methods for coronary artery disease (CAD) are a health priority. Coronary angiography (CA) is currently the gold-standard method for diagnosing CAD. Myocardial perfusion imaging (MPI) is used to diagnose CAD as well. This study aimed to reevaluate the effects of computed tomography (CT)-based attenuation correction on MPI results compared with CA findings.
 
This cross-sectional study enrolled 293 patients referred to Rajaie Cardiovascular Medical and Research Center. The study population underwent MPI with CT-based attenuation correction and CA to diagnose CAD within 3 months.
 
In the right coronary artery (RCA) territory, CT-based attenuation correction led to a significant decrease in MPI sensitivity in men and an increase in specificity in all the patients except those with a normal body mass index. In the left circumflex coronary artery (LCX) territory, a significant reduction in sensitivity was noted just in overweight patients, while specificity improved merely in men. In the left anterior descending artery (LAD) territory, none of the diagnostic parameters changed significantly with attenuation correction.
 
Performing CT-based attenuation correction significantly enhanced diagnostic specificity and worsened sensitivity in the RCA and LCX territories. The advantage of CT-based attenuation correction is more pronounced in patients with a normal body mass index and women. (Iranian Heart Journal 2023; 24(3): 15-23)

Dexmedetomidine reduces perioperative catecholamine concentrations and confers hemodynamic and sympathetic stability. It adjusts coronary blood flow and is known as one of the ideal anesthetic drugs, especially for patients undergoing coronary artery bypass graft surgery (CABG). The present study was performed to evaluate the potential of dexmedetomidine to protect against oxidative stress during CABG.
 
The present double-blinded randomized clinical trial was performed on 58 patients undergoing CABG at Rajaie Cardiovascular Medical and Research Center. After anesthesia induction, the patients were allocated to the trial (dexmedetomidine) and control (normal saline solution) groups. Total antioxidant capacity and malondialdehyde were measured in samples obtained from arterial catheters before the intervention, after pump weaning, and 24 hours after intensive care unit (ICU) admission.
 
Only total antioxidant capacity and malondialdehyde at the third measurement point at the ICU were lower in the trial group than in the control group. The levels of circulatory antioxidants were higher in the trial group than in the control group before the intervention and after pump weaning. No significant differences were observed regarding circulatory antioxidant levels between the trial and control groups.
 
Dexmedetomidine infusion before and during CABG might improve endocardial blood flow and hemodynamic stability among patients undergoing CABG. (Iranian Heart Journal 2023; 24(3): 24-31)

Acute coronary syndrome (ACS) is a type of coronary heart disease responsible for one-third of deaths in individuals older than 35. Registries are a powerful tool to improve patient care and research.
 
We registered 1432 patients with ACS from 2 major tertiary healthcare institutes in Cairo from August 2019 through July 2020. ST-elevation myocardial infarction (STEMI) was reported in 50.6% of the patients, non–ST-elevation myocardial infarction (NSTEMI) in 28.9%, and unstable angina in 20.5%.
 
The mean age was 66.9 ± 11.3 years, 78.4% were male, and 56.4% were current smokers. The most frequent comorbidities were hypertension (52.2%) and diabetes mellitus (47.3%). A history of ischemic heart disease was reported in 24.2%. Both institutes are 24/7 primary percutaneous coronary intervention (PCI)-capable centers; consequently, primary PCI for STEMI patients and invasive strategies for non–ST-elevation ACS patients were done once indicated. Drug-eluting stents were used in 69.7% and bare-metal stents in 30.3% of the patients undergoing primary PCI. The rates of in-hospital major adverse cardiovascular events (MACE) and mortality were 4.8% and 0.8%, respectively. In-hospital and discharge medications were optimal. The potential of different factors as predictors of in-hospital MACE was evaluated using multivariate and univariate analyses. In-hospital MACE occurrence was more frequent in STEMI patients. The multivariate analysis showed that MACE occurred more frequently in STEMI patients with chronic kidney disease, ischemic cardiomyopathy, peripheral arterial disease, a longer door-to-balloon time, and multivessel disease.
 
This registry is one of the largest ACS registries in Cairo, Egypt, covering patient characteristics, risk factors, interventional methods, and medical treatment. (Iranian Heart Journal 2023; 24(3): 32-44)

Coughing during anesthesia or extubation is a probable event that can cause hemodynamic changes due to an increase in chest pressure or the stimulation of the adrenergic system. We aimed to compare the effects of IV lidocaine with those of IV normal saline (as a placebo) on diminishing the incidence of coughs and sore throats, laryngospasms, and hemodynamic changes during tracheal extubation in the ICU after cardiac surgery.
 
The present randomized clinical trial assigned 50 candidates for simple cardiac valve or coronary bypass surgery to 2 groups (each group =25) to receive IV lidocaine or a placebo before tracheal tube removal after cardiac surgery in the ICU. Hemodynamic changes, the level of consciousness-restlessness (RASS), and the incidence of coughs were evaluated in both study groups. Four patients in the lidocaine group and 5 in the control group were lost to follow-up. Finally, 21 patients in the lidocaine group and 20 patients in the control group were analyzed.
 
The rates of hemodynamic changes in the 2 groups were not statistically different. The changes in the level of consciousness based on the RASS were not significant in the 2 groups. The incidence of coughs based on the mentioned 3 criteria showed a statistically significant difference between the lidocaine and placebo groups.
 
IV lidocaine after cardiac surgery can be part of the weaning and extubation process without hemodynamic complications to reduce the incidence of coughs. (Iranian Heart Journal 2023; 24(3): 45-53)

In congenital heart disease, the right ventricle (RV) has been the forgotten chamber for many decades. Congenital atrial septal defect (ASD) leads to volume overload on the RV, while pulmonary hypertension (PH) results in pressure overload. Three-dimensional echocardiography is noninvasive and has become a readily available method for assessing the RV-PA coupling ratio through the division of the RV stroke volume (SV) by RV end-systolic volume (ESV), correlating with RV function. We sought to compare this ratio between ASD (RV volume overload) and PH (RV pressure overload) groups.
 
Ninety patients were divided into 3 equal groups: congenital ASD, PH, and control. Electrocardiography-gated 2D and 3D echocardiographic studies were performed on the study population.
 
The ASD and PH groups showed statistically significant differences regarding RV volume and the RV-PA coupling ratio compared with the control group.  However, the PH group was affected more than the ASD group concerning the RV-PA coupling ratio, with the mean coupling ratio being 1.14 in the ASD group, 0.77 in the PH group, and 1.25 in the control group. The P value between the ASD and control groups was 0.054, while the P value between the PH and control groups was below 0.0001.
 
The RV-PA coupling ratio, measured by 3D echocardiography (RVSV/RVESV), was markedly reduced (uncoupling) in the PH group and to a lesser extent in the ASD group compared with the control group. (Iranian Heart Journal 2023; 24(3): 54-61)

Using echocardiographic parameters, we sought to predict cardiotoxicity in patients with breast cancer before treatment.
 
The study recruited 53 left-sided breast cancer patients with no previous history of heart failure or cancer treatment. The patients underwent 2D and 3D echocardiography before and 6 months after the end of treatment. The main criterion for cardiotoxicity was a reduction in posttreatment LVEF exceeding 10% compared with pretreatment. Systolic and diastolic parameters were compared between 2 groups: complicated and noncomplicated. Binary logistic regression was used to predict cardiotoxicity.
 
The patients’ mean age was 49 ± 11.2 years. No statistical differences existed between the groups in demographics and cardiac risk factors at study commencement. Posttreatment, 4 echocardiographic parameters (E/A ratio, sPAP, LVEF, and LVGLS) were significantly changed compared with pretreatment echocardiography. The regression analysis showed that E/A ratio was effective in predicting cardiotoxicity (sensitivity = 68%, specificity = 76%, AUC =77%; and P <0.001).
 
Echocardiography, aside from its usefulness in diagnosing cardiotoxicity, can be valuable in predicting complications, especially in patients with breast cancer at higher risk of cardiotoxicity due to chemotherapy and radiotherapy in the chest wall area. (Iranian Heart Journal 2023; 24(3): 62-69)

Cardiac resynchronization therapy (CRT) is a safe and effective method to treat heart failure (HF) in selected patients after failed medical therapy. We aimed to compare the effects of left ventricular (LV) lead position on the clinical, electrocardiographic (ECG), and echocardiographic parameters in patients with nonischemic cardiomyopathy (NICM) considering the absence of a large regional scar.
 
Thirty consecutive patients with NICM referred to the Imam Khomeini Hospital Complex for CRT implantation were enrolled in this study. Clinical, ECG, and echocardiographic parameters at baseline and 6 months of follow-up in patients whose left ventricular lead (LV) was implanted in the anterolateral (AL) vs posterolateral (PL) branch of the coronary sinus were compared.
 
The majority of the patients were women (16, 53%). In both groups, functional class improved significantly after CRT implantation, but this decrease was not related to the position of the LV lead. The QRS width in ECG was significantly reduced in the AL group after CRT implantation (from 157.7: 95% CI, 156.13 to 158.27 to 137.3: 95% CI, 133.37 to 141.24; P =0.000). This decrease was also seen in the PL group (from 157.6: 95% CI, 154.26 to 160.01 to 137.6: 95% CI, 133.46 to 141.84; P =0.000), but the decrease was not related to the LV lead position.
 
Our data showed no significant differences in clinical, ECG, or echocardiographic outcomes between PL and AL lead positions in patients receiving CRT. (Iranian Heart Journal 2023; 24(3): 70-76)

Inflammation is crucial to the pathophysiology of atherosclerosis and adverse cardiac events. We aimed to investigate serum procalcitonin levels and SYNTAX scores in subgroups of patients with acute coronary syndromes (ACSs).
 
This cross-sectional study recruited patients admitted for ACSs and categorized them into 3 groups: ST-elevation myocardial infarction (STEMI), non–ST-elevation myocardial infarction (NSTEMI), and unstable angina. Serum procalcitonin and C-reactive protein were measured. The study population underwent percutaneous coronary intervention; then, SYNTAX scores were analyzed.
 
The STEMI (64.86%) and NSTEMI (46.86%) groups were more likely to have positive procalcitonin than the unstable angina group (11.11%) (P =0.002). The mean procalcitonin level was significantly higher in the STEMI group (0.95 ± 0.47) than in the NSTEMI (0.62 ± 0.30) and unstable angina (0.05 ± 0.30) groups (P =0.001). SYNTAX scores were statistically significant in the 3 groups (P =0.004). Multivariate regression analysis indicated significant relationships between procalcitonin levels and ACS subgroups (β = -0.28, P =0.001), triple-vessel disease (β =0.07, P = 0.010), all-cause in-hospital mortality (β = 0.68, P =0.003), and the SYNTAX score (β = 0.72, P =0.004).
 
Serum procalcitonin may be associated with coronary artery disease severity measured with the SYNTAX score. Future studies should evaluate the prognostic accuracy of procalcitonin levels in patients with ACSs. (Iranian Heart Journal 2023; 24(3): 77-84)

The crisscross heart is a rare congenital heart abnormality often associated with other cardiac anomalies. Echocardiography is the first-line diagnostic tool, whereas magnetic resonance imaging and catheterization are used for complementary assessments. In the absence of significant pulmonary valve stenosis or hypoplasia in the tricuspid valve or the right ventricle, total repair or, otherwise, the Fontan procedure is recommended. (Iranian Heart Journal 2023; 24(3): 85-88)

Wound infection after cardiac catheterization is uncommon.1 Fracture does not seem to have been reported in association with a mechanical compression device. In this case, an elderly woman experienced 2 complications after angiography: cellulitis and fracture. The patient was referred to a dermatologist and orthopedic surgeon for definitive treatment. Advanced age, hospitalization, poor hand hygiene management, and hemostasis device mechanisms could be highlighted as risk factors for the complications. This case report provides learning points for cardiologists to access the radial artery and shows that early recognition of risk factors is fundamental to preventing and managing these complications. (Iranian Heart Journal 2023; 24(3): 89-93)

Difficult intubation in pediatric patients with a history of relatively common respiratory and cardiac problems and syndromic cases should always be considered. Pierre Robin syndrome is a rare birth defect characterized by a small jaw, tongue retraction, and upper airway obstruction, also known as Pierre Robin syndrome.

Case Report:

 We describe a 5-month-old boy, 3500 g in weight, suffering from Pierre Robin syndrome. The patient was a candidate for the surgical closure of ventricular septal defect (VSD) and patent ductus arteriosus (PDA). After the induction of anesthesia in the operating room, we encountered problems with intubation in that it was not possible to secure an airway with a tracheal tube via different methods. The patient woke up, and the surgery was postponed. His airway was then thoroughly evaluated before VSD and PDA surgical closure was performed successfully.

In elective surgical cases with unexpectedly challenging intubation, the surgery should be postponed until the airway is fully checked and a safe airway is secured. (Iranian Heart Journal 2023; 24(3): 94-99)

The COVID-19 pandemic has been unresolved for 3 years. Numerous individuals have survived COVID-19 but suffered from a variety of problems or symptoms for several months. This report presents our experience regarding a post–COVID-19 patient with exacerbated symptoms of congestive heart failure and congestive hepatopathy.

Two months after being diagnosed with COVID-19, a 47-year-old man presented to Universitas Islam Indonesia Hospital with significant shortness of breath and abdominal enlargement. Cardiomegaly, increased jugular venous pressure, hepatomegaly, ascites, and bilateral edema of the legs were all indicators of congestive heart failure. Cardiomegaly was discovered on a chest X-ray. Electrocardiography revealed ischemic heart illness with an old myocardial infarction. Aspartate transaminase (911 U/L), alanine transaminase (820 U/L), and total bilirubin (4-6 mg/dL) were increased. Ultrasonography of the abdomen demonstrated congestive hepatopathy with ascites. Echocardiography showed hypokinetic cardiac wall movements and a 21% decrease in the ejection fraction. He had a comorbidity of uncontrolled diabetes mellitus. The symptoms subsided after therapy with furosemide, spironolactone, dobutamine, nebivolol, sacubitril, valsartan, L-ornithine-L-aspartate, insulin, and a broad spectrum of antibiotics. After 10 days of hospitalization with comprehensive management, the patient’s condition improved.

Our post–COVID-19 patient suffering from congestive heart failure with a poor ejection fraction and severe congestive hepatopathy had an improved outcome following our comprehensive management. (Iranian Heart Journal 2023; 24(3): 100-107)

Although the COVID-19 pandemic started over 2 years ago, the uncertainty regarding the management of this severe disease continues to prevail. We describe a patient with aortic valve endocarditis complicated by COVID-19 postoperatively. Given increased symptom severity during reinfection, it is important to highlight the need for the long-term follow-up of these patients since they might be prone to another episode of COVID-19. (Iranian Heart Journal 2023; 24(3): 108-110)