Iranian Heart Journal
Volume:11 Issue: 2, Summer 2010

As an invaluable surgical tool, autologous pericardium has been successfully used to repair many cardiac lesions. The encouraging results from its use in repairing heart valves have been applied to repair tricuspid valve regurgitation (TR). In the present study, we report our preliminary results using autologous pericardium as an alternative surgical technique in repairing tricuspid valve insufficiency. Method From June 2002 to November 2006, 22 patients (mean age 39.7 years) with heart valve disease underwent tricuspid valve repair by anterior leaflet augmentation with glutaraldehydetreated autologous pericardium. Nineteen patients (86.4%) had pure tricuspid valve regurgitation (TR), while the remaining three patients (13.6%) had significant associated tricuspid valve stenosis in whom commissurotomy was carried out. TR was considered severe in 18 patients and moderate to severe in four cases. All had associated left-sided heart valve surgery, except two patients. Concomitant adjustable tricuspid annuloplasty by pericardial band was performed in 12 patients. The mean follow-up period was 10.39 months (range 1 to 42 months). Result There was one in-hospital death due to postoperative multiorgan failure. One patient developed partial detachment of the pericardial patch, which was successfully repaired. Echocardiography data showed a significant decrease in the severity of TR: trivial to mild in 68.2% (n=15), mild to moderate in 22.7% (n=5), and moderate to severe in 9.1% (n=2) of the patients. Conclusion Anterior tricuspid leaflet augmentation is a safe, effective and appealing surgical technique in dealing with patients with tricuspid valve regurgitation. Further studies are, however, mandatory to evaluate its long-term outcome.

Background Pulmonary regurgitation (PR) is the most important residual lesion remaining after the repair of Tetralogy of Fallot (TOF). Through a thorough review of the data, statistics of patients undergoing pulmonary valve replacement following total correction for TOF and analyzing these data, the following study was performed and presented below. Method Database search for medical records of patients undergoing pulmonary valve replacement following total correction for TOF was performed and the data gathered, analyzed, and presented. Result The age of the patients (22.21±6.98 years old), time elapsed between the two operations, right ventricular ejection fraction (mildly decreased, 18.6%; moderately decreased, 67.9%; and severely decreased, 12.2% of cases), aneurysm in the outflow tract of the right ventricle (20.8%), tricuspid regurgitation (56.6%), tricuspid stenosis (1 case), valve type used for pulmonary valve replacement (biologic, 86.6%; metallic, 11.2%; and homograft, 1.9%), pulmonary artery pressure [<25mmHg, 34 cases (64.2%); 25mmHg - 50mmHg, 7 cases (13.2%); 50mmHg - 75mmHg, 1 case (1.9%), and > 75mmHg, 1 case] were evaluated. Conclusion Although right ventricular volume overload due to severe pulmonary regurgitation after repair of TOF can be tolerated for years, there is now evidence that the compensatory mechanisms of the right ventricular myocardium ultimately fail and that if the volume overload is not eliminated or reduced, this dysfunction may be irreversible. In light of those data and with better understanding of risk factors for adverse outcomes late after TOF repair, many centers are now recommending early pulmonary valve replacement before symptoms of heart failure develop.

Background Balloon pulmonary valvuloplasty (BPV) has emerged as the treatment of choice for patients with valvular pulmonary stenosis (PS). We report here our short and long–term outcomes of BPV in 64 patients with isolated native PS. Method From February 1996 to February 2006, sixty–four patients with PS (pressure gradients? 40 mm Hg) were enrolled in this retrospective study. Result The hemodynamic data at catheterization revealed that the RV - PA pressure gradient before BPV ranged from 40 to 240 mmHg (mean ± SD = 93.2 ± 43.4 mmHg). The above gradient immediately after BPV ranged from 5 to 163 mmHg (mean ± SD = 30.3 ± 27.7 mmHg), and the difference was significant (p=0.0037). Twenty-three patients had regular follow–up. The duration of follow– up ranged from 1-120 months with a mean of 38.5 ± 31.3 months. The transvalvar pressure gradient during the above period ranged from 10 to 140 mmHg with a mean of 35.9 ± 27.9 mmHg and showed a significant difference (p = 0.0032) with the pressure gradients before BPV. Conclusion BPV provides short and mid-term relief of pulmonary valve obstruction in the majority of patients.

Background The purpose of this study was to investigate whether there is any relation between mitral leaflet motion based on height-to-length ratio of the anterior mitral valve leaflet doming in diastole and the immediate outcome of balloon mitral valvuloplasty,. Method The study population consisted of 49 patients (47 women, mean age: 43.7±13.35 years) with symptomatic rheumatic mitral stenosis who underwent balloon valvuloplasty. Complete transthoracic and transesophageal studies were performed in all the patients before valvuloplasty, and transthoracic study was repeated 24-48 hours after valvuloplasty. The severity of the restriction of the mitral valve leaflet motion was classified based on the heightto- length ratio of the anterior mitral valve leaflet doming. Mitral valve thickness, calcification, subvalvular thickening, and mobility were scored according to the Wilkins system. Optimal immediate outcome of balloon mitral valvuloplasty was defined as a valve area improvement of 50% or more or a final mitral valve area of? 1.5 cm2 and mitral regurgitation Seller's grade? 2. Result There was a significant relation between the total mitral valve score and its thickness with the optimal immediate post-balloon mitral valvuloplasty results (p value=0.03 and 0.04, respectively), but no relation was found between the Wilkins score and its components with the anterior mitral valve leaflet height-to-length ratio. There was no significant relationship between the amount of increase in the mitral valve area, decrease in trans-mitral pressure gradients, decrease in pulmonary artery pressure, and anterior mitral leaflet height-to-length ratio (all p values > 0.05; all the correlation coefficients < 0.2). Conclusion Our study showed that post-balloon mitral valvuloplasty results are mainly affected by valve thickness and the total Wilkins score. In addition, the severity of mitral leaflet motion restriction in terms of the height-to-length ratio of the anterior mitral valve leaflet has no significant relation with the immediate result of balloon mitral valvuloplasty.

Background Deep venous thrombosis is an increasingly common disorder which consumes remarkable human and financial resources. The objective of the current study is to compare the cost of current methods of heparin therapy; unfractioned heparin (UFH) and lowmolecular weight heparin (LMWH), in deep venous thrombosis (DVT). Method This was a cross-sectional study on 146 patients with DVT which was carried out at our cardiology ward between 2002 and 2004. The number of admission days and the total inpatient and out-patient costs of therapy were estimated. Result The results revealed that in-patient treatment with standard heparin (UFH) costs U.S. $240.00 with a mean of 8.5 days of hospital stay, while treatment with LMWH (enoxaparin) costs U.S. $80.00. Conclusion 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, costeffectiveness and better individual and social activities during the treatment period, it is suggested that LMWH be used at least in low-risk patients instead of intravenous heparin, while also sparing them hospital admission.

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious and underdiagnosed disorder with significant morbidity and mortality. It is thought to result from single or recurrent pulmonary thromboemboli arising from the sites of venous thrombosis, often from the lower limbs. Surgical correction of anatomical obstructions (endarterectomy of pulmonary artery) is the treatment of choice in these patients, and the patients’ outcomes are good. The mortality rate in some centers is about 5%, but in others it is up to 30%. Method We started pulmonary endarterectomy in Shaheed Rajaie Heart Center (RHC) in Iran four years ago. Pulmonary thromboendarterectomy is performed under hypothermia and total circulatory arrest with cardiopulmonary bypass. All patients are evaluated in our hospital for known risk factors of deep vein thrombosis and pulmonary emboli. Right heart catheterization and measurement of pulmonary artery pressure and vascular resistance are performed in some of the patients and left heart catheterization in those who are over 45 years of age. CT angiography of the pulmonary artery with multi-slice CT scan is done in all patients before and after endarterectomy. Patient selection for successful endarterectomy is based on CT angiography and perfusion lung scan with consideration of pulmonary vascular resistance in some cases. Result During a 4-year period, 15 patients (5 female and 10 male) underwent this type of surgery in RHC. Their mean age was 35.87 (min. 18, max. 55) years old. The mean pulmonary artery systolic pressure by echocardiography was 87.60 mmHg (min. 55mmHg, max. 140 mmHg, SD 23.26 mmHg) and the mean pulmonary artery pressure was 46.43mmHg (min. 23 mmHg, max. 60 mmHg, SD 11.70 mmHg). Mean surgery time was 5.33 hours (min. 4hrs, max. 14 hrs, SD. 2.46 hrs), mean bypass time was 138 minutes (min. 84, max. 220, SD=43.28 minutes), mean intubation time was 49.88 hours (min. 7 hrs, max. 216 hrs, SD 61.66 hrs), and intensive care unit stay time was 5.43 days (min. 3, max. 9, SD=1.98). Two fatalities occurred due to bleeding and shock. The mortality rate was 20%. IVC filters were placed in a minority of the patients who had clear-cut evidence of lower extremity deep vein thrombus as a cause of pulmonary thromboembolic events. Conclusion Pulmonary endarterectomy is the treatment of choice in CTEPH with an acceptable mortality rate and a good prognosis. It is possible to perform this procedure without recourse to more sophisticated evaluations with an acceptable mortality rate in patients who have segmental lobar or main pulmonary artery organized clot.

We report our experience with 117 patients with primary cardiac tumors who underwent surgery at our institute (a referral center) between March 1995 and February 2006. The patients comprised 47 men and 70 women with a mean age of 44.97 years (range: 2.5- 81 years). The predominant symptom was dyspnea on exertion and palpitation. In all the patients, echocardiography was the main diagnostic tool, but magnetic resonance imaging (MRI) and CT scan and coronary angiography were also performed if indicated. Most of the tumors were found in the left atrium (LA) (77.77%), but the other chambers were also involved with lesser prevalence (right atrium: 7.5%, left ventricle: 5.1%, and right ventricle: 2.5%). Involvement of multiple chambers was found in 8 (6.8%) patients. All the patients survived the surgical procedure and were discharged from hospital. Follow-up ranged from 1-10 years (mean: 2.4 years). The most prevalent tumor was myxoma (104 cases), followed by sarcoma (4 cases) and fibroma (2 cases). Four patients had secondary (metastatic) cardiac tumors (two Hodgkin lymphoma, one renal cell carcinoma, and one osteosarcoma) and were consequently excluded from the study.

Background Secondary atrial septal defect is one of the most common congenital heart diseases, and treatment is required in cases of large defects. The aim of this study was to assess the short-term results of secundum atrial septal defect closure by two surgery (right thoracotomy) and intervention (transcatheter Amplatzer septal occluder). Method This is a descriptive study on 25 patients treated by one of the two above-mentioned methods at our center between 2004 and 2007. The patients underwent clinical and diagnostic examinations both before and after treatment such as chest X-ray, electrocardiography, echocardiography, catheterization, and angiography. The outcome and results were thereafter assessed and compared. Result The study population was comprised of 20 (80%) females and 5 (20%) males. The patients were divided into two groups: 17 (68%) patients were treated by intervention and 8 (32%) by right thoracotomy. The intervention group had a mean age of 12 years (±6years) and the surgery group 11 years (±4 years). The average size of the defect was approximately 15 mm, which was similar in both groups. The average duration of hospital stay in the intervention group was significantly shorter than that of the surgery group, and the average cost of treatment in the intervention group was slightly less than the surgery group. One of the patients in the surgery group needed blood transfusion, and one of the patients in the intervention group suffered from Amplatzer embolization to the left ventricle, necessitating the extraction of the device through open heart surgery. One of the patients in the surgery group had a residual defect in the atrial septum, which was not significant. Conclusion In light of the results of this study, it seems that in appropriately selected patients, the closure of the atrial septal defect via the interventional method is comparable to surgery.

A 42-year-old man presented with orthopnea, paroxysmal nocturnal dyspnea, and ascites, which had progressed for the previous two months. Electrocardiogram was low voltage. Transthoracic echocardiography showed concentric left ventricular hypertrophy and increased brightness and speckling pattern in the ventricular septum, consistent with amyloidosis. Cardiac magnetic resonance imaging confirmed the echocardiographic findings, and gingival biopsy was positive for amyloidosis.