Iranian Heart Journal
Volume:9 Issue: 1, Spring 2008

Endovascular aortic repair (EVAR), as a new and less invasive method for treatment ofaortic aneurysms, has shown lower short term complications than routine open surgical repairs. Inthis report we present our results with the first consecutive series of this technique in our patients.
From Dec. 2006, we began a prospective case series of EVAR patients for the first time inIran, and so far, 15 consecutive patients (1 female, 14 male) with the mean age of 66 years (range36 to 89 years old) underwent endovascular aortic aneurysm repair (3 thoracic, 11 abdominal, 1combined thoracic and abdominal) with Medtronic “Talent” or “Valiant” stent grafts. In-hospitaland one month follow up results are reported as short-term outcome.
Results:All 12 abdominal aorta aneurysms (AAA) were infrarenal with an acceptable proximal neck. Ineight patients, associated iliac aneurysms were seen. For 11 AAA patients, routine modular stentgrafts were used and in one case, unilateral stent graft was implanted because of difficulty ofcontrolateral stent graft implantation. Four thoracic aorta aneurysms (TAA) were repaired withValiant stent grafts. One of them was a Marfan patient with recent Bentall surgery and two werepost-surgery saccular aneurysms. In all 15 cases, stent graft implantation was done successfully. Infive cases, mild type II endoleak was seen at the end of the procedure, which was no longerpresent on one month follow up. One patient had post- procedure cerebral stroke with delayed
mortality. No other major complications were seen in 1 month follow up in the other 14 cases.Minor complications like vascular access hematoma, anemia and increased creatinine were
controlled on hospital stay period in some cases. Control CT angiography in some patients
revealed no endoleak or aneurysm enlargement and 6 and 12-month follow up assessment will bedone for mid-term results.
Endovascular repair of aortic aneurysm is feasible and safe for suitable cases based on bothclinical and radiologic findings. Good case selection, good device selection and suitable follow up

Peripartum cardiomyopathy is a type of cardiomyopathy found in pregnancy and up to 5
months after delivery. There is no identifiable cause for myocardial dysfunction in these
patients. In this study, we evaluated our patients for symptoms, signs, functional class,
prognosis and complications.
Eighteen pregnant patients with myocardial dysfunction and diagnosis of peripartumcardiomyopathy were evaluated from Dec. 1998 to Dec. 2007. All patients hadechocardiography follow up, and symptoms and signs of every patient were evaluated for 5years.Results- Mean age of patients was 34±5 yrs, mean left ventricular ejection fraction (LVEF)according to echo was 27±5%, and dyspnea was present in 100% of patients. Chest pain waspresent in 61.11%, arrhythmia in 50%, edema in 72.22% and hypertension in 27.77%. Duringfollow up, there were 22.22% next pregnancies in 5 years. Mortality occurred in 16.66%,remission in 27.77%, partial resolution of symptoms and signs and improved LVEF in22.22%, and no improvement in 33.33%. Vaginal delivery was performed in 77.77% andcesarean section in 22.22% of patients.
Peripartum cardiomyopathy is a lethal disease during pregnancy. We do notrecommend allowing next pregnancies and cesarean section is lethal; vaginal delivery is thebest method of parturition for these patients ).

Percutaneous coronary intervention (PCI) is an invasive procedure which traumatizesthe coronary vessel wall and serves as a potent stimulus for thrombus formation.Unfractionated heparin is used routinely during the procedures to reduce the likelihood ofacute thrombotic complications. Activated clotting time (ACT) is the preferred assay todetermine the degree of anticoagulation during PCI. Our aim was to assess ACT values duringPCI after administering heparin with conventional dose (10000 u) and determining ischemicand bleeding complications.
Coronary artery disease (CAD) patients (N=205) receiving conventional heparin dose andundergoing PCI were included in this study. ACT was assessed 10 minutes after heparin injection. Demographic data and cardiovascular risk factors were registered in the forms andthe patients were followed up for about one month for complications.
ACT range 10 minutes after heparin injection was 160 – 682 sec (mean 353 sec, SD: 94.5sec). ACT was lower than 250 in 12.7% of patients (95% CI: 8.2%-17.2%). ACT had a rangeof 250-350 seconds in 37% of patients. Overall, 21 patients (10.3%) had ischemiccomplications (including chest pain, new ischemic changes in EKG, unstable angina and 2deaths) and 3 patients (1.5%) had bleeding complications. Ischemic complications weresignificantly higher in smokers (16%) versus nonsmokers (6%, P=0.038) and in patients with≥2 risk factors (12%) versus those with £1 risk factor (4%, P=0.046). All three patients withbleeding complications were hypertensive (P=0.02).
Although this study shows relative safety of conventional heparin dose in PCI, butonly about one third of our patients reached desired ACT values (250-350 sec). So it seemsappropriate to use weight adjusted heparin doses (e.g. 100u/kg) instead of conventional doseand to assess ACT in all patients and use additional heparin doses to maintain ACT at optimal

Infective endocarditis is a disease caused by the microbial infection of the endothelium,which covers the inner layer of the heart. Different studies in advanced countries have reported theincidence of the disease from 1.6 to 6 in 100,000 patients.
This retrospective analysis was conducted at Shaheed Madani Hospital of Tabriz between 1995 and 1999. The patients who lacked diagnostic symptoms of endocarditis, and those who were diagnosed on the basis of clinical signs were excluded from the study, and 20 patients whohad endocarditis of the native valves were studied. The information was collected through aquestionnaire including demographic information, blood samplings, pathologic results, reports ofechocardiography and radiology, feverish syndromes, records of antibiotic use, and the signs of disease. Information was analyzed using the statistical program of SPSS WIN.
Twenty patients at an average age of 34 years with native valve endocarditis were selected for the study. 65% of these patients were male and 35% were female, and 17 patients had completeresults of their blood culture test.Staphylococcus aureus was obtained in 11.67% of the cases, andtwo cases were positive for beta-hemolytic streptococcus (11.72%). In the analysis of cardiac
complications, none of the patients had myocardial infarction and angina, 6 cases had embolism,10% had no arrhythmias, and another 10% had heart block. Three of the patients had neurologic lesions, and radiological findings in 9 cases were abnormal. Eleven patients underwent open-heartsurgery. The minimum duration of hospitalization was 6 days and the maximum 94 days. 80% ofthe patients recovered, while 20% died. Three patients had Brucella endocarditis, which was diagnosed via the Wright test. The most common site of infection was the aortic valve.
Rheumatic fever is a universal disease, the outbreak of which is very high in the countries
which have poor economic conditions, are overpopulated, and have substandard living conditions.
These conditions cause the rapid transmission of rheumatogenic streptococcus. Improving these
conditions and proper and timely antimicrobial treatment can decrease the prevalence of rheumatic

Atrial septal defect (ASD) operation is a safe and low-risk procedure. Cosmetic results have been an important issue, so right anterolateral thoracotomy (RALT) approach has been used for repair. However, inRALT, the skin incision usually crosses the future breast line, which may cause breast mal-development.
We reviewed the long-term results of a consecutive series of 406 patients from 1997- 2005 in whom the ASDwas closed through a RALT or median sternotomy (MS) incision. 190 patients were male and 216 were
female, with a mean age of 8.2±3.9 years. Defects repaired included 383 ASD secundum (ASD 2º) and 23 ASDsinus venosus type (ASD-SV). In 316 patients (77.8%), the defect was closed through MS, and 90 patients(22.2%) underwent RALT for repair.
The mean cardiopulmonary bypass time (CPB time) was 37.0±10 min. for MS vs. 40±11 min. for RALT
(p=0.9, NS). Intubation time after operation was 9.0±5 hrs for MS and 8.1 ±7.1 hr in RALT (p=0.8, NS).Postoperative drainage was 119mL (range, 0-1100mL) for MS and 94mL (range, 0-500mL) in RALT (p=0.1,NS). Postoperative pleural/pericardial effusion and pneumothorax occurred in 2.1% of patients in MS and6.6% in RALT group (p= 0.001). There was no operative or late mortality, morbidity or breast maldevelopment
in the long-term follow-up (range, 6 m -10 y, mean 4 yrs).
RALT is a safe and effective alternative approach to MS incision for ASD closure (Iranian Heart

Lp (a) lipoprotein has structural homology with plasminogen and has been shown to inhibit plasminogen activation in vitro and, therefore, the effect of streptokinase (SK). SK’s effect is also inhibited by anti-streptokinase antibody (anti SK Ab). We sought to determine whether the serum concentration of Lp (a) lipoprotein present when SK was given in acute myocardial infarction (AMI) influenced the outcome in spite of low anti-streptokinaseantibody, as judged by electrocardiography methods.
Serum Lp (a) lipoprotein concentration was measured in 135 consecutive patients admitted with a diagnosis of AMI who received SK treatment. Recovery and non-recovery from myocardial injury was assessed by the reduction in sum of ST segment elevation measured from the J point (STJ) and Q wave formation in electrocardiography immediately before SK was given compared with two hours later.
50% (median decrease) had a mean serum Lp (a) lipoproteinconcentration of 18mg/dl. The difference was not statistically significant.
In this study, Lp (a) lipoprotein concentration did not significantly influence the
outcome of thrombolytic treatment with SK ).

Bicuspid aortic valve (BAV) is the most common congenital heart disease and the most common malformation of aortic valve. In BAV, there are two cusps instead of three cusps in the aortic valve. The objectives of this study were the determination of the aortic rootdilatation and other anatomic and hemodynamic characteristics and abnormalities of BAV.
Thirty patients and 30 control subjects were evaluated. Aortic root dimensions were measured via two-dimensional echocardiography (2-D echo) at 4 levels, including the aorticvalve annulus, sinuses of Valsalva, sinotubular junction (STJ) and proximal ascending aorta (AAO). Hemodynamic data and anatomic characteristics were measured using 2D and Doppler-echo. All the findings were matched and indexed for body surface area (BSA) and were compared with the matched data of the control subjects. Clinical and demographicfindings of BAV were also determined and collected through a questionnaire.
Among the patients, 70% were male and the mean age and weight of the patients were 7.5 years and 22.13 kg, respectively. 86.66% of the patients had systolic ejection murmur (SEM),76.66% systolic ejection click (SEC) and 10% had chest pain. Other congenital heart diseases(CHD) were found in 26.96% of the patients, including coarctation of the aorta (CoA) in 23%of the cases. Matched mean anatomic aortic valve area (AAVA) was 2.05cm2/m2 , and matched mean effective aortic valve area (EAVA) was 1.41cm2/m2 BSA. Maximum aortic valve pressure gradient (PG max) in systole was 56.56mmHg. Forty percent of the patients had aortic stenosis (AS): mild AS in 16.66%, moderate AS in 13.33% and intermediate AS in 10%.Prevalence of aortic insufficiency (AI) was 36.68%. When the data were compared with thecontrol subjects, all the patients showed a meaningful larger aortic root dimension at all 4
levels (P values are presented in Table IV). Aortic root dilation was at the level of the annulus,sinuses of Valsalva, STJ and proximal AAO in 6.25%, 4.75%, 10.20% and 10.13%,
respectively.
These findings support the hypothesis that BAV and aortic root dilation may reflect a common developmental defect. AS and AI are common in BAV. Similar to other obstructive defects of the left heart, BAV is significantly more common in males. Because murmurs and clicks are common in BAV even without AS or AI, all patients with a heart murmur and/or click must be evaluated for BAV

Coronary artery bypass grafting surgery (CABG) is a commonly performedprocedure. More than 10,000 CABG surgery procedures are performed in Iran annually.Prolonged mechanical ventilation following CABG surgery is uncommon. Economic factorshave led to a trend for early tracheal extubation after CABG. Fast-track extubation is variouslydefined but most agree that it refers to extubation within 8 hours.
A descriptive observational study was conducted on 196 patients undergoing CABG
surgery. Following surgery, standard weaning protocol was implemented. Patients who failed to be extubated within 8 hrs were evaluated.
Four patients (2.04%) died within 3 to 12 days. After undergoing surgery, the minimum duration of mechanical ventilation was 2 hrs, up to a maximum duration of 19 days. 94.3% of the patients were extubated within 24 hrs, with a mean duration of 9.54 hrs. 5.7% of the patients were still intubated after 24h. The most common cause of delayed extubation was physician trend (n=27, 13.8% of patients). Reduced ejection fraction, EKG changes, elderly age, prolonged CPB, difficult intubation were reasons for this trend. The second most common cause was excessive postoperative bleeding, which occurred in 13.3% of the patients.Four percent of the patients were returned to the operating room for re-exploration.
Cardiovascular instability (11.7%), metabolic acidosis (9.7%), prolonged recovery (4.7%),
neurologic problems (2%), poor FVC (4.6%), hypoxemia (1.5%), and acute respiratory
distress syndrome (ARDS) (0.5%) were other reasons.
The incidence of prolonged mechanical ventilation for more than 24h was similar tothat of the STS database.8 We found the most common cause of delayed extubation to be physician trend. We recommend changing our strategy in these patients. Excessivepostoperative bleeding incidence in our study was slightly higher than that in other studies.We found the proportion of patients with failure to extubate due to various reasons would vary from institution to institution, based on differences in patient population and managementstrategies).

Increase in trauma and aging in recent decades has been associated with an increase in orthopedicoperations in the limbs and their concomitant iatrogenic vascular complications. Although vascular injuries during orthopedic operations are uncommon, timely diagnosis and treatment is essential.These injuries can occur due to laceration, compression, or traction of the vessels in proximity to bony structures such as vertebrae, hip and knee joints, and long bones. Primary signs are bleeding or ischemia. The best results will be obtained with prompt diagnosis and treatment; otherwise, there is a risk of complications such as pseudoaneurysm or limb loss.
The presented case is a 22-year-old male with a history of right tibial fracture following a
motorcycle accident one year before, which was treated with internal plate fixation. Following the operation, an enlarging mass developed in the posterior aspect of his leg. Upon evaluation, it was noted that a screw used for internal fixation had injured the posterior tibial artery and led to tibial artery pseudoaneurysm. Surgical treatment was done. Such a complication has not been reported in the literature. In the presence of even minimal ischemia following bone trauma, vascular evaluation and angiography before any orthopedic operation is critical, and it is recommended thatmanagement in such cases be performed in centers where reconstructive vascular surgery is

Coronary artery fistula is a rare congenital anomaly with an incidence of about 0.2 - 0.6% in different reports. It is defined as a direct communication between the coronary artery and any surrounding cardiac chamber or vascular structure which bypasses the myocardial capillary bed.Three interesting cases of coronary artery fistula are reported. Two of the patients were symptomatic. In one case, all coronary arteries (in addition to duplicated LAD) were fistulized into the right ventricle. Diagnosis was made by echocardiographic study and coronary angiography. Surgical correction is discussed. In one case, angiography six months later showed no fistula. Serialechocardiography during follow-up was unremarkable