The Journal of Tehran University Heart Center
Volume:3 Issue: 2, Apr 2008

Echocardiography plays a fundamental role in the evaluation of patients with an intracardiac mass. The ability to distinguish tissue characteristics, location, attachment, shape, size, and mobility non-invasively, quickly, and without the use of ionizing radiation makes echocardiography the ideal diagnostic modality. With careful attention to mass location and morphology, and appropriate application of clinical information, echocardiography can usually distinguish between the three principal intracardiac masses: tumor, thrombus, and vegetation. Equivocal transthoracic findings typically indicate the need for a transesophageal evaluation, during which the atria and great vessels might be better imaged. Surgical intervention is often indicated based on possible echocardiographic findings, without the need for additional time-consuming procedures. This review will focus on cardiac tumors.

The presence of significant carotid stenosis in coronary artery bypass grafting (CABG) patients increases the risk of either transient ischemic attack or stroke. However, there is a dearth of data on the risk for patients with unilateral total occlusion of the carotid artery. We herein report our results of cardiac surgery in patients with unilateral total occlusion of the carotid artery. We examined 10,000 patients who underwent carotid artery duplex scanning before CABG or other cardiac procedures between January 2001 and September 2006 at Tehran Heart Center. The occlusions were detected via carotid Doppler screening and were confirmed through conventional or MR angiography. Among these patients, 15 (0.15%) patients had unilateral total occlusion of the internal carotid artery, and all of them underwent elective cardiac surgery. During cardiopulmonary bypass, the mean arterial pressure was maintained at above 60 mmHg with vasopressure drugs and increasing flow pump. There were 4 patients with left and 11 patients with right carotid occlusions. Four patients had a history of cerebrovascular accident. The mean cross-clamp time (min) and perfusion time (min) was 50.7±17.3 and 94.2±26.7, respectively. The mean graft number was 4.1±0.9. One of these patients expired intraoperatively because of low cardiac output. In one (6.66%) patient, postoperative cerebrovascular accident occurred on the contralateral side of the totally occluded region. All the patients recovered uneventfully. Our results suggest that CABG can be performed in patients with unilateral total occlusion of the internal carotid artery without ipsilateral stroke using our strategies.

Complete atrioventricular block (AV block) is a serious complication of slow pathway ablation therapy in the treatment of atrioventricular nodal re-entrant tachycardia (AVNRT). The present study was aimed at determining whether the electroanatomical pace mapping of Koch’s triangle could significantly improve the safety, efficiency, and efficacy of selective slow pathway ablation in the treatment of AVNRT. A total number of 124 patients were selected to be studied consecutively for radiofrequency (RF) ablation therapy in the treatment of AVNRT. The subjects were divided into two groups: one, designated Group 1, to serve as the control group, and the other, designated Group 2, to serve as the study group. Conventional fluoroscopic slow pathway ablation was performed on the Group 1 subjects (n=66), with the Group 2 subjects receiving slow pathway ablation therapy guided by pace mapping of Koch’s triangle. The slow pathway ablation in Group 2 (n=58) was performed with regard to the pace mapping data obtained on the basis of the St-H interval in the anteroseptal (AS), midseptal (MS), and posteroseptal (PS) regions of Koch’s triangle. The anterograde fast pathway (AFP) location was determined based on the shortest St-H interval obtained by stimulating the anteroseptal (AS), midseptal (MS), and posteroseptal (PS) aspects of Koch’s triangle. In the Group 2 subjects, AFP location was AS in 50 (86.2%) of the cases, MS in 7 (12%) of the cases, and PS in 1 case (1.7%). One patient with posteroseptal AFP was administered retrograde fast pathway ablation therapy. One patient in the control group (Group 1), representing 1.5% of the group, developed persistent AV block in the course of the treatment, but none of the subjects in the study group (Group 2) developed any complications. It was concluded that an atypical fast pathway location is conducive to the development of atrioventricular block in the ablation therapy in AVNRT, with pace mapping of Koch’s triangle having the capacity to eliminate the risk of any such complication developing. It follows that it helps to identify the AFP location before ablation therapy is administered in AVNRT, thereby improving the safety of the treatment.

This study was undertaken to compare the outcome in patients with moderate to severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with either mitral valve repair or mitral valve replacement. Between March 2002 and February 2005, 49 consecutive patients (mean age: 62.84±8.42 years; mean EuroSCORE: 10.03±3.12) with coronary artery disease and moderate to severe IMR underwent CABG plus mitral valve replacement or mitral valve repair. The patients with annulus dilatation were more likely to undergo repair. The mean follow-up period was 18.89±2.1 months. 40.8% of the patients underwent CABG plus mitral valve replacement, and 59.2% had CABG concomitant with mitral valve repair. The total rate of mortality in our population was 14.9% (7 patients) including 10.3% (3 patients) early mortalities; all the deceased patients were in the repair group. Both groups had a similar EuroSCORE, but more patients in the repair group had a recent episode of unstable angina (65.5% vs. 35.0%, respectively; P=0.035) and diabetes mellitus (44.8% vs. 10.0%, respectively; P=0.009). After the follow-up period, in the repair group, 11.5% had no features of Mitral regurgitation (MR); while 50% had mild MR, 23.1% moderate MR, 11.5% moderately severe MR, and 3.8% severe MR. Overall, 68.9% had no or mild MR, which we defined as successful repair, and 31.1% had moderate to severe MR. Success of repair and mortality were not statistically related to preoperative ejection fraction (39.2±7.8% vs. 32.5±8.5%; P=0.057). Early mortality was higher in the repair group than that in the replacement group, but this may have been due to the higher frequency of diabetes mellitus and unstable angina in the former group. Future studies are required to determine the benefit of repair versus replacement concomitant with CABG in IMR patients.

We sought to assess right ventricular (RV) systolic and diastolic functions via tissue Doppler imaging (TDI) in order to discriminate right-to-left (bidirectional) from left-to-right intracardiac shunts. A tissue Doppler velocity study via Doppler echocardiography was performed in 20 patients with left-to-right shunt (without evidence of significant pulmonary hypertension) and 20 patients with right-to-left shunt or bidirectional shunt (with significant pulmonary hypertension) or Eisenmenger΄s complex and 20 healthy subjects as the control group. RV myocardial performance index (MPI), S wave velocity, E wave velocity, isovolumic relaxation time (IVRT), and isovolumic contraction time (IVCT) from the lateral tricuspid annulus were measured using TDI. In the patients with left-to-right shunt, the tissue Doppler parameters showed higher S-wave, peak systolic(Sa)/early contraction(Ea), Sa/IVRT, and Sa/IVCT values; and in the patients with right-to-left or bidirectional shunt tissue, the Doppler parameters showed higher MPI and MPI/Sa value with a high specificity and sensitivity. We conclude that an evaluation of MPI, S wave, E wave, IVRT, and IVCT via tissue Doppler echocardiography is a useful index for the discrimination of right-to-left from left-to-right and bidirectional intracardiac shunts.

The Short Form Health Survey (SF-36) and WHO Quality of Life-BREF (WHOQOL-BREF) questionnaires are two common tools to assess changes in quality of life (QOL) over the course of treatment, especially in patients with coronary artery disease (CAD). However, the value of these two instruments among CAD patients has not been studied and compared. The objective of the present study was; therefore, to compare the SF-36 with the WHOQOL-BREF in these patients. Between May and September 2006, patients with a final diagnosis of CAD who were candidates for isolated coronary artery bypass grafting (CABG) and hospitalized in Tehran Heart Center were randomly divided into two groups of 268 patients (for assessment of QOL with the SF-36) and 275 patients (for assessment of QOL with the WHOQOL-BREF). The correlations between the WHOQOL-BREF domains and SF-36 subscales, in addition to those between the SF-36 components summary scores and WHOQOL-BREF domains, were examined with Pearson''s correlation coefficients. The correlations between the physical, psychological, and social domains of the WHOQOL-BREF and physical functioning, mental health, and social functioning of the SF-36 were weak with Pearson''s correlation coefficients of 0.015, -0.036, and 0.042, respectively (r<0.3). There were also poor correlations between the physical component summary of the SF-36 and physical domain of the WHOQOL-BREF (r=0.001), and between the mental component summary of the SF-36 and mental domain of the WHOQOL-BREF (r=-0.082). The correlation between the two questionnaires of the SF-36 and WHOQOL-BREF in the evaluation of QOL in CAD patients is weak.

Severe and prolonged physical training is associated with morphological and physiological cardiac changes, often termed as the “athlete’s heart”. Echocardiographic features peculiar to elite Iranian athletes have not been previously described. The aim was to examine the echocardiographic characteristics of highly trained Iranian athletes involved in three different sports. We studied cardiac morphology and function as assessed by rest echocardiography in 50 elite adult male athletes referring to a university hospital in Tehran between February 2001 and March 2006. Resting ejection fraction, interventricular septal wall thickness (IVSWT), left ventricular posterior wall thickness (LVPWT), left ventricular internal end diastolic dimension (LVEdD), left ventricular internal systolic dimension (LVIsD), left ventricular (LV) mass, and relative wall thickness (RWT) were measured. The control group consisted of 50 age- and weight-matched normal healthy men. Of the athletes, 38 were engaged in predominantly dynamic (running and soccer) and 12 in predominantly static (weightlifting) sports. The overall mean LVEdD (51.06±5.49mm) and IVSWT (10.24±1.43mm) were higher in the athletes than those in the normal subjects. The mean of IVSWT in the 38 endurance-trained athletes was significantly more than that of the 12 strength-trained athletes (11.1 mm vs. 10.3 mm, P<0.05). LVEdD was also greater in the endurance-trained athletes, but the difference was not statistically significant (51.2 mm vs. 50.6 mm). Our results of higher LVEdD and IVSWT in Iranian male athletes are in line with previous reports. To generalize the results, we require more studies with larger sample sizes (with female athletes included).

This is a case presentation of a 26-year-old woman with a moderate-sized atrial septal secundum defect (17mm) who underwent catheterism, during which an Amplatzer Septal Occluder number 26 was inserted successfully. On the second postoperative day, she deteriorated and a clinical examination showed a typical tamponade. After a percutaneous aspiration of the pericardial cavity and transient improvement in vital signs, a pig-tail catheter was inserted percutaneously emergently, and the patient was transferred to the operating room in a preshock state. During the operation, an active bleeding point in the superoanterior aspect of the right atrium near the aortic root was detected, which was repaired by direct suture and pericardial patch reinforcement. The Amplatzer device was removed and the atrial septal defect was repaired with a pericardial patch. A lethal complication of the interventional closure of atrial septal defect, properly treated by an emergent intervention and operation, is presented and discussed herein.