Iranian Heart Journal
Volume:3 Issue: 3, Winter 2002

Objectives- This research was performed to assess systolic and diastolic left ventricular function in patients with ventricular and AV sequential pacing, placing particular emphasis on the long-term evaluation of left ventricular function in ventricular and AV sequential pacing. We also compared the short-term effects of different modes of pacing on LV function.Methods- We conducted a prospective one-year echocardiographic study on 40 patients with ventricular and AV sequential pacemakers at our center in Tehran. Echocardiography was done before and 1 week, 2, 6 and 12 months after pacemaker implantation. Systolic and diastolic functions were assessed as well.Results- 12 (30%) women and 28 (70%) men aged 65.32±13.11 years were recruited in the study. 32 (80%) had advanced AV block and 8 (20%) had sick sinus syndrome. End diastolic volume, stroke volume, and ejection fraction were significantly decreased (p<0.01) in ventricular pacing group in short and long–term evaluations. In AV sequential pacing group, end diastolic volume, end systolic volume, and stroke volume were significantly decreased (p<0.01 for both).Conclusion- In spite of a decreased ejection fraction, ventricular pacing can improve cardiac output both in short and long-terms, but AV sequential pacing improves cardiac output by increasing both ejection fraction and the heart rate. Diastolic function assessment by echo is not as reliable as in systolic function.)

Background- Noninvasive methods for identification of accessory pathway(s) (AP) location in pre-excitation syndrome have always been desirable. Given the noninvasiveness and other advantages of radionuclide ventriculography (RVG), this study was performed to verify the efficacy of RVG in determining the location of accessorypathway(s) in patients with Wolff-Parkinson –White (WPW) syndrome.Methods- Fourteen patients with WPW syndrome were enrolled in this study and they underwent RVG scanning followed by electrophysiologic study (EPS) within a couple of days.Results- After we compared the scintigraphic and electrophysiologic results, RVG showed that 11 patients had one AP and 3 patients had dual APs. The existence of dual pathways were confirmed by EPS only in two patients. RVG did not identify dual pathways in one patient.Conclusion- We concluded that RVG scanning could be considered as a noninvasive procedure before EPS. Considering the location of APs, RVG identified their location in comparison with EPS) in 78.8% of the patients.;

Background- By the end of 2000, more than 10,000 patients had received renal transplants in the Islamic Republic of Iran (IRI), and this number is expected to increase yearly. Since the 1-year survival rate for renal transplant recipients is approaching 90% and is continuing to improve annually, an increasing number of patients who have received renal transplants present for coronary artery bypass graft (CABG) surgery. They represent a technically demanding group of patients who require special consideration regarding preserving renal graft function and minimizing possible complications of cardiac surgery. This study was conducted to evaluate the outcome in renal transplant patients undergoing CABG surgery.Patients and Methods- We prospectively studied seventeen renal transplant patients with approximately normal preoperative renal function (plasma creatinine 1.1-1.5 mg/dL) scheduled for elective coronary artery bypass surgery. Various aspects of anesthesia and the surgical procedures were assessed as regards the function of the transplanted kidney.Results- Renal blood flow and renal transplant function are influenced before the induction of anesthesia, after sternotomy and before cardiopulmonary bypass (CPB), during hypothermic CPB and normothermic CPB, after sternal closure, and postoperativebleeding.Conclusion- Protective interventions are very important in renal transplant patients undergoing coronary artery bypass graft surgery to prevent deterioration of renal function. Hemofiltration was performed routinely to prevent volume overload and excessive hemodilution. We used low-dose dopamine infusion (renal dose) throughout the operation and phenylephrine infusion during cardiopulmonary bypass..

Background and Objectives- Although exercise test is a highly reliable procedure for diagnosis of coronary artery disease (CAD), its value in assessing the extent and severity of CAD is yet unexplained. The present study aims to examine the relation between severity of ST segment depression in treadmill exercise test and left ventricular performance, number of involved arteries and severity of coronary artery disease.Patients and Methods- This prospective, cross-sectional case control study of 103 patients was conducted in 1995 at Shahid Rajaie Heart Center, Tehran, Iran. The inclusion criteria were a) having stable angina pectoris, having abnormal exercise test findings, being a candidate for coronary angiography and b) having abnormal coronary angiography findings and being a candidate for exercise test. Any evidence of unstable angina pectoris, or history of myocardial infarction or other heart disease comprised the exclusion criteria.Findings- ST segment depression in V4-V6 chest leads upon exercise test were meaningfully related to triple-vessel disease. However, no relation was found between severity and timing of ST segment depression in exercise test and triple-vessel disease. Depression of ST segment in the inferior chest leads with exercise test was an indicator of single-vessel disease; nevertheless, it did not suggest the disease of any particular vessel. No relation was observed between ST segment depression in exercise test and left ventricular dysfunction. The prevalence of ST segment elevation during exercise test was low and there were no statistically significant findings.):

Background- Stress echocardiography is one of the non-invasive methods to diagnose coronary artery disease. Myocardial wall motion abnormality, caused by pharmacological and non-pharmacological procedures performed upon the patients suffering from coronary artery disease, is observed and analyzed by this method.Patients and Material- One hundred and three cases, who had undergone stressechocardiography, were researched on over one year in the stress echocardiography unitof Rajai Heart Center. We compared the results of the stress echocardiography and theresults of the angiography. The patients’ ages varied from 32 to 73 years (mean 48.9).The two methods of exercise stress echocardiography and dobutamine stress echocardiography were adopted.Results- In this analysis, the sensitivity and specificity for the diagnosis of CAD were respectively 89.4 and 82.5 percent. The sensitivity and specificity for the diagnosis of LAD lesions were 79.6 and 87, for RCA lesions 80.6 and 82.3 and for LCX lesions 58.1 and 89 percent respectively. The sensitivity and specifity for the diagnosis of the posteriorcirculation system (RCA and LCX territories) were 90% and 75% respectively. Duringthe study, no severe complications (VF, MI, death) occurred; however, one case suffering severe ischemia ended up in CCU. Moreover, arrhythmia in 3 patients (2.9%), hypertension in 9 patients (8.8%), for one of whom the test was interrupted due to severehypertension, hypotension in one patient (1%), and non-cardiac complications such asvertigo, nausea and headache in 13 patients (12.6%) were reported.Conclusion- Considering the results gained in this study, and also the low rate ofcomplications and similar results with radionuclide scanning, which has proved moreexpensive and apt to make patients exposed to radiation, this test as a non-invasive testbefore coronary angiography is recommended.;

Background- Composite aortic root replacement is the accepted treatment for acute dissections of the ascending aorta involving the root with aortic valve regurgitation, but controversy continues over the best technique of operation.Methods- We reviewed all cases who underwent emergency operations in an over two-year period in our center for acute dissections of the ascending aorta in order to determine the surgeon’s preference concerning the technique of the operation and the outcome of the patients. Twenty-five patients underwent emergency surgery for acute ascending aortic dissections from Jan. 1998 to Jan. 2000. There were 21 male (84%) and 4 female patients (16%), and the average age was 48 years (range 25 to 68 years).Results- Hospital death occurred in 5 (20%) patients. Return to the operating room for bleeding was required in 9 patients, and hospital mortality due to bleeding was 3 patients. Neurological deficits developed in 3 patients in the immediate postoperative period, two of whom recovered completely. The third patient also had renal and multiple organ failure and died. One patient required tracheostomy and ventilatory support for 3 weeks. This patient finally died because of sternal infection and sepsis. Echocardiogram was done on follow-up for all patients, and showed no evidence of coronary or other anastomotic disruption. No reoperations were needed for anastomotic aneurysms at any site.Conclusion- Higher bleeding and mortality rates in our series compared to those reported in the literature can be reduced with the newly introduced gelatin-coated graft material. Ourtechnique includes excision of the dissected aortic wall, implantation of a composite valvegraftconduit, direct coronary implantation to the graft and distal anastomosis to the divided aorta.

Background and Objective- Atherosclerotic coronary artery disease is an important cause of mortality worldwide. Huge economic burdens, various health complications and high mortality due to atherosclerotic coronary artery disease necessitate the identification and control of its risk factors. In addition to serving as the underlying cause of many coronaryartery- disease risk factors, low socioeconomic status seems to act as an independent risk factor during childhood and adolescence for the development of cardiovascular diseases later in life. The objective of this study is to assess the influence of socioeconomic status during childhood, alongside other known risk factors, on the development of cardiovascular diseases.Patients and Methods- This is a prospective, case-control study of 600 patients in private and state-run university hospitals with coronary care units. The patients were matched for sex, age and characteristics other than those under study. We assessed the influence of socioeconomic status in childhood, alongside other known risk factors, on the development of coronary artery disease.Results- Men constituted 69.1% and 65.2% of the case and control groups respectively. The two groups were similar in terms of the patients’ mean age. Most of the women were housewives, and men were typically occupied in jobs involving little physical activity. 47.5% and 45.5% of the patients in the case group belonged to the lower and middleincome brackets, respectively. 35.6% and 58.16% of the patients in the control group belonged to the lower and middle-income brackets respectively, showing a statistically significant difference from the case group. Positive family history of cardiovascular disease, cigarette smoking, hypertension, diabetes, obesity and hyperlipidemia were other risk factors of coronary artery disease in the case group as suggested by this study, with a statistically significant difference from the control group.Conclusion- The income difference between the case and control groups was significant in terms of developing coronary artery disease. Similar studies have also pointed to a higher chance of developing atherosclerotic coronary artery disease in individuals belonging to the lower-income brackets during their childhood. Our findings regarding the influence of cigarette smoking, positive family history of cardiovascular disease, diabetes, hypertension, hyperlipidemia and obesity on the development of coronary artery disease are consistent with the results of similar studies in other parts of the world. These findings call for new measures to be taken by community health authorities and policy makers to curb the everincreasing incidence of cardiovascular diseases in the society.

Background- Patients with symptomatic sinus node disease require a permanent pacemakerto relieve symptoms. This study was conducted retrospectively in patients who hadreceived a ventricular pacemaker for sick sinus syndrome and was designed to analyzethe incidence of complications and long-term survival in sinus node disease treated withventricular pacing.Patients and Methods- Eighty-two adult patients between the ages of 20 and 90 years oldwith symptomatic sinus node disease who received a permanent ventricular pacemakerbetween 1979 and 1996 at our department were followed to determine the natural historyof the disease. 31 had coronary artery disease, 26 had hypertension, 7 had rheumaticvalvular heart disease, and diabetes and mitral valve prolapse were present in 7 and 2patients, respectively. The etiology was unknown in 9 patients.Results- 3 patients had died during this period because of congestive heart failure andischemic heart disease. There was a distinct trend toward poor survival in those withcongestive heart failure and old age.Conclusion- The long-term prognosis of symptomatic sinus node disease after permanentventricular pacing depends on: 1) etiology of underlying heart disease, 2) ventricularfunction prior to implant, and 3) specific arrhythmias.;

ORIGINAL ARTICLES: CLINICAL SCIENCE Echocardiographic Study of LV Function in Patients with 6Ventricular and AV Sequential PacingM. Maleki, MD; M. Haghjou, MD Diagnostic Efficacy of Radionuclide Ventriculography in Identifying the 11Location of Accessory Pathway(s) in Wolff –Parkinson –White SyndromeS. Hekmat, MD; F. Rastgoo, MD; M.A. Sadr-Ameli, MD; N. Yaghoobi, MD;H. Firouzabadi, MD; S. Seifollahi, MD; M. Mohammadi, MD Anesthetic Management in Patients with Renal Transplant 14Undergoing Coronary Bypass Graft SurgeryG. Mollasadeghi, MD; E. Heidarpour, MD; M.H. Kalantar Motamedi, MD;R. Farasatkish, MD; K. Raissi, MD Evaluation of the Relation between Electrocardiographic 21Changes during Exercise Test and Anatomy of CoronaryArtery in Coronary AngiographyM. Garak Yaraghi, MD; M. Maleki, MD; A. Pourmoghaddas, MD Correlation of Wall Motion Abnormality by Stress 26Echocardiography and Anatomic Site of Coronary Artery LesionsH. Rashidinejad, MD; F. Noohi, MD; Z. Ojaghi, MD;A. Honarmand, MD; M. Maleki, MD Evaluation of Emergency Composite Aortic Root Replacement 30with Direct Coronary Artery ImplantationK. Raissi, MD, M. Sina, MD, M.H. Kalantar Motamedi, MD Socioeconomic Status Alongside Other Risk Factors of 34Atherosclerotic Coronary Artery DiseaseA. Pourmoghaddas, MD; M. Garak Yaraghi, MD Natural History of Symptomatic Sinus Node Disease After 39Permanent Ventricular PacingH. Azarnik, MD; S. Homayounfar, MD; M.A. Sadr Ameli, MD; K. Raissi, MD Non-cardiac Surgery in Valvular Heart Disease 44J. Golshahi, MD; S. Aram, MD

Background- Rheumatic heart disease (RHD), which is one of the most common causes of cardiovascular mortality and morbidity in the world, occurs following repeated episodes of rheumatic fever (RF) recurrences. This study evaluated the RF recurrences to verify the clinical features of the disease and to determine the related risk factors in recurrences.Methods- The medical charts of 38 cases of confirmed RF with recurrence who were admitted to our Pediatric Cardiology Unit from March 1995 to March 2001 werereviewed and evaluated. All demographic data and injection schedules were completelyrecorded.Results- Of the 38 patients with recurrent RF, 25 (65.8%) were girls and 13 (34.2%) were boys. Their age at the time of their first attack ranged from 4 to 13 years with a mean (±SD) of 8.14 (±2.8) years. Carditis was the most common major manifestation (86.8%). Pure chorea was seen in 4 (10.5%) of the patients (2 boys and 2 girls) and isolated arthritis occurred only in one (2.6%) case. Major clinical manifestations were not statistically different in both sexes (p=0.38). Of the 38 patients, 37 (97.4%) cases were not on penicillin prophylaxis at the time of recurrence. In 15 (39.5%) of the patients, medical staff were responsible for the discontinuation of prevention and in 22 (57.9%) patients, secondary prophylaxis was stopped because of their own or their families’refusal.Conclusions- The present study supports the need to concentrate on optimizing adherence tosecondary prophylactic regimens in the years immediately following an episode of ARFand to assure medical staff and patients of the long-term benefits of benzathine penicillinadministration to prevent recurrent RF.)

Background- Atrial fibrillation (AF) is a common complication of heart surgery. This unwanted sequel leads to an increased risk of thromboembolism and necessitates further often costly health care. Advanced age, previous AF rhythm, and valvular heart disease are the most consistently identified risk factors for the development of this rhythm after cardiac surgical procedures. Dispersion of repolarization leading to reentry is believed to be the mechanism of postoperative AF. Treatment is aimed at controlling heart rate, preventing thromboembolic events, and converting to sinus rhythm.Material- 500 consecutive patients who were undergoing cardiac surgical procedures consisting of coronary artery bypass, valve procedures and combined coronary-valve procedures were prospectively evaluated to determine the predisposing factors relating to the development of postoperative AF rhythm.Results- In this series of 500 patients undergoing cardiac operations at our center, we found the incidence of AF to be 13% after coronary artery bypass grafting (CABG), 24% after mitral valve replacement, 23% after aortic valve replacement, and 32% after combined CABG and valve replacement procedures. Patient age, valvular heart disease, preoperative AF rhythm, and discontinuation of beta-blockers were shown to bestatistically significant in determining the development of postoperative AF rhythm in ourgroup of patients.Conclusion- The only firm conclusion that can be drawn concerning preventive measures is that beta-blocker withdrawal is to be avoided after heart operations and to consider betablocker therapy for other patients who may tolerate these drugs in order to reduce the chances of developing AF rhythm.)

A 22- year-old male with history of aortic prosthetic valve replacement 3 months prior to admission was operated on emergently due to prosthetic valve endocarditis (PVE) unresponsive to medical therapy with a large mobile vegetational mass extending to LV. On operation there was a large friable vegetational mass engulfing the mechanical prosthetic valve. The partially detached prosthetic valve and vegetations were removed and aortic root replacement by aortic Homograft and coronaries implantation were performed. The patient was discharged from ICU four days after operation with good condition. The result of two cultures from the prosthetic valve was Aspergillus. Amphotericine-B was started and all other antibiotics were discontinued. The patient remained afebrile and in good condition but CT scan of brain revealed three SOL in frontal and occipital lobes. This case suggests that early and proper surgical treatment may reduce the risk of complications and mortality.