Iranian Heart Journal
Volume:10 Issue: 4, Winter 2009

Elevated plasma homocysteine (Hcy) is considered to be a novel risk factor for coronary atherosclerosis. Considering the important role of the kidneys in Hcy clearance, the relation, if any, between Hcy and diabetes mellitus (DM) and coronary artery disease (CAD) in diabetic patients is still unclear. The aim of this study was to investigate whether plasma Hcy is a predictor of CAD in patients with type 2 DM without any evidence of nephropathy.

Among type 2 DM patients without nephropathy (cr£1.2 mg/dl) referring for coronary angiography to Tehran Heart Center during 2005, 151 patients were evaluated in this cross sectional study. CAD was confirmed if there was a lumen diameter narrowing > 50 percent in at least one coronary artery. The extent of CAD was determined by the number of affected coronary arteries.

The mean±SD Hcy level was 11.35±3.7 mmol/l. No significant difference was observed between the CAD and control groups (11.52±4.01 mmol/l vs.11.02±3.11 mmol/l, p=0.440).CAD was related to body mass index (p=0.044), systolic blood pressure (p=0.027), HDL-c level (p=0.016), serum creatinine (p=0.042), and HbA1c level (p=0.001). A binary logistic regression analysis found systolic blood pressure (OR: 0.96, p=0.003), creatinine (OR: 24.76, p=0.013), and HbA1c (OR: 2.41, p=0.017) as independent predictors of the presence of CAD.Predictors of the extent of CAD were history of hypertension and current smoking.

In the presence of normal renal function, plasma Hcy level cannot predict either presence or extent of CAD in patients with type 2 DM without nephropathy.

Transcatheter closure of small to moderate patent ductus arteriosus (PDA) has been well established during this last decade. The Amplatzer device occluder (ADO) is a self expandable device with ease of delivery and a rapid learning curve. The aim of the study was to access the optimum sizing of ADO in regard to maximum efficacy with respect to shunt occlusion without oversizing and reducing bulk and potential protrusions.

From April 2007 to July 2008, a total of twenty-four adult PDA closures were reviewed.Occlusion was achieved via antegrade venous approach. Our primary objective was an evaluation of optimum ADO sizing for PDA closures. We retrospectively compared the patients with a theoretical optimum size as regards complications and residual shunts.

PDA size determination was based on the smallest diameter at pulmonary artery (PA) side.Based on specific criteria, undersizing was not observed in our cases, while oversizing was noted in 42% of cases. Oversizing did not lead to a decrease in residual shunts (37.5% vs. 36%, p=NS). Although no short-term complications were observed in the oversized group, oversizing resulted in a characteristic mushroom deformity due to unnecessary tension applied to our device. The Chinese device also performed well in terms of deployment and short-term complications with no significant difference in comparison to its American counterpart (p=NS).

An acceptable rate of acute complications was obtained; nonetheless, we were frequently oversizing, leading to mild device deformation and protrusion. Although not previously described in the literature, the terminal ballooning of the ADO should alert us of such a complication.

Acute normovolemic hemodilution (ANH) includes the removal of blood from a patient either immediately before or shortly after the induction of anesthesia and the simultaneous replacement with an appropriate volume of plasma substitute to maintain normovolemia. Thromboelastography (TEG) is a non-invasive diagnostic approach designed to monitor and analyze the coagulability state of a blood sample in order to assist clinical assessment of the haemostatic condition of the patient. The aim of this study was to use the ANH technique in patients requiring coronary artery bypass graft (CABG) surgery and to confirm the advantages of the ANH technique along with TEG.

A controlled randomized clinical trial was conducted in 130 patients (32 females, mean age 57±9.0 years, range 38 to 79 years) who were scheduled for CABG surgery with cardiopulmonary bypass (CPB). They were equally divided into two equal-sized ANH and control groups (n=65). Patients in group A underwent ANH with an average of 500 ml whole blood removal after the induction of anesthesia and their removed blood was replaced with crystalloid solution; blood was not removed in the subjects of the control group. Serum levels of hemoglobin and platelets, TEG parameters analysis, homodynamic changes before and after the operation, and the amount of blood transfused during surgery and in the ICU were checked in both groups. Statistical analysis was performed using repeated measures ANOVA models.

After the surgery, there were significant decreases in hemoglobin and platelets levels (p<0.005), but the decrease was less in the ANH group. However, no difference was found in the amount of platelets decrease between the two groups. Changes in TEG parameters - K, ANGLE, EPL and CI – in the ANH group were statistically significant before and after the surgery (all p-values<0.05). Also, there were significant differences in MA, EPL, and CI parameters between the ANH and control groups (all p-values<0.05).

Use of ANH in patients undergoing CABG surgery results in greater preservation of coagulation factors and platelets that may reduce the amount of bleeding.

Coronary artery disease (CAD) risk factors are increasing in developing counties.Previous studies have shown a high prevalence of CAD risk factors in Iran but geographical prevalence is not uniform. We performed this study to determine the prevalence of these risk factors in Yazd province, central Iran.

In this cross-sectional study, a total of 2000 participants, 1000 men and 1000 women among Yazd citizens, were surveyed and data was recorded in a 500-item questionnaire.

About 85% of Yazd citizens had at least one and 61.1% had at least two coronary artery disease risk factors. The present study showed that 16.38% of Yazd citizens were obese (9.2% in men and 24.2% in women), and 43.3% of men and 62.05% of women had excess weight.Prevalence of hypercholesterolemia was 12.1% (10.6% in men and 13.8% in women, respectively), dyslipidemia 58.5% (59% and 57.6%, respectively), high blood pressure (HTN) 25.6% (27.5% and 23.5%, respectively), diabetes mellitus (DM) 11% (10.48% and 11.5%, respectively), impaired glucose tolerance 8.5% (7.9% and 9.1%, respectively) and cigarette smoking 13.12% (24.45% and 0.5%, respectively). The prevalence of hypercholesterolemia, dyslipidemia, DM, HTN, and abdominal obesity increased significantly with age (p<0.005).The prevalence of obesity, abdominal obesity, hypercholesterolemia and DM was significantly higher in women.

Excess weight, dyslipidemia and HTN were the most prevalent risk factors in Yazd.Although Yazd did not have the highest levels of risk factors in Iran, but the findings showed that Yazd is one of the “at risk” cities with regard to prevalence of risk factors. Preventive and therapeutic programs should thus be considered as a major health priority in Yazd.

Mediastinal bleeding and blood transfusion have been an important accompaniment of open heart surgery. Increasing attempts are being made to minimize blood loss and blood transfusion in cardiac surgery. We investigated the effect of intraoperative autologous donation (IAD) on need for homologous transfusion post-coronary artery bypass graft surgery (CABG).

202 adult patients scheduled for elective CABG operation were randomly assigned to IAD (n=101) or control groups (n=101). We obtained 500ml fresh whole blood from the IAD patients while the patients were prepared for anesthesia in the operating room. This amount of blood was replaced with Ringer's solution. After completion of the operation and neutralization of heparin, this blood was re-infused to the patients. The amount of bleeding and infused blood products were measured and compared in both groups.

The present study demonstrated that IAD did not significantly reduce post-operative mediastinal bleeding, although it had a positive effect on reducing homologous transfusion.

It seems that IAD can reduce homologous blood transfusion (although not significantly), but for prevention of bleeding some simple points such as mild hypothermia instead of moderate hypothermia, reduced heparin dose with newer tubing systems and oxygenators and precise hemostasis are more prominent.

This is a single institute retrospective study (from 2007 to 2008) to evaluate how patient related factors (age, weight) and type or anatomical location of ventricular septal defect (VSD) could affect the outcome of surgery.Methods- Patients with any diagnosis who had undergone ventricular septal defect repair (a total of 252 patients) from 2007 till early 2008 at our center were evaluated retrospectively for factors which might be responsible for developing residual ventricular septal defects and heart block.Data were analyzed through univariate and multivariate analysis. There was 2 deaths among 252 patients (0.8%). The incidence of postoperative residual ventricular septal defect was 28.2%±2.8* (71 of 252), but only 3 of them (4.2%) needed reoperation. Neither patch material (p=0.572), nor type (p=0.349) or size (p=0.599) of ventricular septal defect had any effect on this complication. The mean age and weight of patients who had residual ventricular septal defect compared to those who did not were not significantly different, although they were somewhat lower (4.7±0.7 vs.5.2±0.4 years, p=0.537; and 15.4±1.7 vs.17.9±1.1 kg, p=0.222, respectively). There were five patients (2.0%) with postoperative complete heart block (CHB) and again this was independent of the patients’ age, weight and surgical approach (transatrial or transventricular). Patients with history of previous Blalock-Taussig (BT) shunt proved to have postoperative bleeding more commonly (13%, 6 of 46 patients) than patients who had not (3.4%, or 7 of 206 patients, p=0.009). Also in patients with a history of BT shunt compared to those without it, postoperative pericardial effusion (6.5% versus 1.5%, P=0.04) and pneumonia (4.3% versus 0.5%, P=0.025) were more common. It seems that for VSD repair, there are no limitations such as weight or age to proceed with the definitive surgery. Also the incidence of complications is independent of the type of anomaly or approaches for closing the defect. Finally, BT shunt has its own complications which are neither rare nor minor, so it is advisable to proceed with the definitive surgery at the first time to avoid the complications associated with BT shunt.

We present an 18-year-old male who sought medical attention due to exertional dyspnea of a few weeks' duration. His physical exam revealed an elevated jugular venous pressure, facial puffiness, muffled heart sounds, and mild lower extremity pitting edema.Chest X-ray showed cardiomegaly; and in echocardiography, huge intrapericardial masses with massive pericardial effusion were noted. The only noteworthy finding on abdominal ultrasonography and CT scan was the presence of ascites. The only abnormal laboratory results consisted of a hemoglobin level of 10.8 g/dl, a 1-hr ESR 77, CRP 34 mg/dl and LDH 771. Some 1500cc pericardial fluid was aspirated, and two multilobated creamy-brown masses with foci of necrosis and hemorrhage were excised.Microscopically, hypercellular sheets of malignant round cells were seen. Based on morphology, a diagnosis of high-grade round cell sarcoma was made. Immunohistochemical markers were negative for cytokeratin, CD 34, desmin, and smooth muscle actin, while positive reactivity was noted only for vimentin. Therefore, the cells were mesenchymal in origin with no vascular, skeletal, or smooth muscle differentiation and the final diagnosis was undifferentiated sarcoma.The patient was discharged in good clinical condition and underwent chemoradiation therapy.

We describe neglected inferior sinus venosus atrial septal defect in a patient with history of surgical repair of secundum type ASD nineteen years ago. The defect was in the inferior portion of the interatrial septum just at the orifice of the inferior vena cava, far from the previous surgical patch of the secundum ASD repair. Preoperative and/or intraoperative transesophageal echocardiography is necessary for detection of multiple ASDs and reveals the successful repair of sinus venosus defects.

Deep venous thrombosis (DVT) is a fast-growing disease which is being dedicated significant human and financial resources. The objective of the current study was to compare the cost of current methods of heparin therapy; unfractioned heparin (UFH) and low molecular weight heparin (LMWH), in the treatment of deep venous thrombosis. This was a cross-sectional study on 146 patients with DVT which was carried out at the cardiology ward between 2002 and 2004. The number of admission days and the total inpatient and out-patient costs of therapy were evaluated. The results revealed that in-patient treatment with standard heparin (UFH) cost US $240.with a mean 8.5 days of hospital stay, while treatment with LMWH (Enoxaparin) cost US $80. Considering all the benefits of LMWH including desired efficacy, greater ease of administration, fewer laboratory monitoring requirements, earlier hospital discharge, feasibility of using LMWH safely on an outpatient basis instead of an in-patient basis, cost effectiveness and better individual and social activities during the treatment period, it is suggested that LMWH at least be used in low-risk patients instead of intravenous heparin, also sparing them hospital admission.

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease (KD) has been rarely reported in adolescent patients. We report a young adult with no coronary risk factors but with a giant solitary coronary aneurysm with obstructive thrombosis inside, presumably secondary to KD, who underwent coronary artery bypass grafting (CABG) with left internal thoracic artery (LITA) and SVG.Because coronary artery sequelae of KD can be a cause of ischemic heart disease even in young adults, heightened awareness of this entity is required for young adults with coronary lesions but without coronary risk factors.

Chronic pulmonary thromboembolic disease is entrapment of thrombus in pulmonary arteries from a single episode or repeated embolic episodes that subsequently organize, or thrombi that develop inside the pulmonary arteries into firm, fibrous tissue that becomes incorporated into the vessel wall.We operated 7 patients with end stage chronic pulmonary thromboembolism over a two year period at our center. Four patients had good function class after operation on follow up at 6 to 12 months and we administered warfarin prophylaxis (with international normalized ratio, INR, of 3) for them.Three patients died in hospital postoperatively. We used extracorporeal membrane oxygenation (ECMO) for one of them but it failed on the third postoperative day.