Iranian Heart Journal
Volume:11 Issue: 4, Winter 2011

A sizable portion of patients with angina pectoris secondary to underlying coronary artery disease (CAD) can be effectively treated. Anti-anginal medication has proven efficacious in most patients, and percutaneous coronary revascularization or coronary artery bypass grafting can successfully treat the rest. Low-level laser therapy (LLLT) via its direct, heat-independent effect on the process of tissue repair may play a significant role in the treatment of patients with advanced CAD. We aimed at assessing the safety and efficacy of LLLT in advanced multi-vessel CAD patients not suitable for myocardial revascularization. We evaluated various clinical parameters as well as the results of laboratory tests to seek the indices of the potential impact of laser therapy on the study population. Methods Twenty-two patients (mean age, 61 years old and male gender, 68.1%) with advanced CAD and a history of myocardial infarction underwent two series of irradiation therapy, each series comprising 10 sessions of LLLT and conducted with a three-month interval. In each series, LLLT was administered every other day for 20 minutes per session (excluding one session that lasted only 10 minutes). The pre-laser evaluation consisted of blood pressure, heart rate, basic biochemical test, electrocardiogram (ECG), six-minute walk test, transthoracic echocardiography, and ECG-gated single photon emission computed tomography (SPECT) perfusion imaging. Three months later, the pre-laser evaluation was repeated. Results No side effects associated with laser biostimulation or performed clinical tests were noted. An improvement in functional class, and distance covered in the six-minute walk test and decrease in systolic blood pressure was observed. There was also a significant change in the myocardial perfusion of most anterior segments of the heart according to SPECT (visually and by computer software, P<0.05). There was no significant change in diastolic blood pressure, heart rate, left ventricular ejection fraction by transthoracic echocardiography, and ECGgated SPECT. Conclusions LLLT resulted in an improvement in functional capacity and myocardial perfusion as well as a reduction in the frequency of angina symptoms during the six-minute walk test. There were no significant changes, however, in the left ventricular function according to transthoracic echocardiography and ECG-gated SPECT. In the short term, LLLT proved to be a safe method. These encouraging results should be confirmed by larger, placebo-controlled studies.

Background Hypertension is associated with microalbuminuria. However, the true prevalence of microalbuminuria in patients with hypertension has not been yet defined and appears to be higher than expected, mostly in patients with poor blood pressure control. The United Arab Emirates (UAE) society is comprised of multinationals, and the prevalence of microalbuminuria in those patients can reflect the approximate prevalence all over the world. The purpose of this study was to assess the prevalence of microalbuminuria in hypertensive patients living in the UAE and to assess its correlation with other cardiovascular (CV) risk factors. Methods Data on all hypertensive patients and normal controls were collected in NMC Hospital, Dubai, between 2008 and 2009. A single urine specimen was collected for the quantitative determination of albumin in human urine. Fasting venous blood was sampled for high sensitive C-reactive protein (hs-CRP) and lipid profile including total cholesterol (TC), triglycerides (TG), high density lipoprotein (HDL), and low density lipoprotein (LDL). Results A total of 86 patients with a mean age of 47.6 years with uncomplicated hypertension were studied, out of whom 68.6% were males. The prevalence of microalbuminuria was significantly higher (50.6%) in the hypertensive patients than in the controls (10.3%, p value=0.0001). No significant correlation was observed between microalbuminuria and systolic blood pressure (SBP, r= -0.153, p value=0.519), diastolic blood pressure (DBP, r= 0.116, p value=0.625), or body-mass index (BMI, r= 0.301, p value=0.119 or hs-CRP (r= 0.115, p value=0.472). Conclusions Microalbuminuria is common in hypertensive patients, and as a result, these patients should be screened for microalbuminuria (Iranian Heart Journal 2010; 11 (4):16 -20).

Background Spontaneous recall of events during general anesthesia is called awareness. Awareness during the operation is common in coronary artery bypass grafting (CABG), especially in urgent cases and in patients with unstable hemodynamic condition before the operation. A standard method for the measurement of the depth of anesthesia (DoA) has not yet been introduced. A variety of techniques have been used for monitoring DoA like electroencephalography (EEG), monitoring muscle movement in the distal esophagus, and new methods of auditory evoked potentials (AEPs) and bispectra index (BIS). Recently, a more sensitive method, called aepEX which is a modified form of AEPs, has been used for the monitoring and controlling of DoA. This study was designed to compare the sensitivity of the aepEX system with the BIS system for DoA monitoring using current clinical and paraclinical methods. Methods In this prospective, controlled trial, 36 patients who were candidates for CABG were enrolled in the study. All the patients underwent a standard induction method for anesthesia with remifentanil, atracurium, and midazolam. Before anesthesia, both aepEX and BIS monitoring systems were controlled simultaneously in each patient. These systems had no effect on each other. Finally, all data about DoA, clinical data of awareness including BP, tear secretion, hemodynamic information, and demographic characteristics were collected and analyzed. Results This study compared the monitoring techniques for DoA, BIS, and aepEX. Results of this study were diagrams for the comparison of BIS and aepEX in different stages during CABG. According to these diagrams, essential analysis could be done about the quality of these two systems in DoA. Conclusions Our data demonstrated that the aepEX monitoring system had greater sensitivity in all the stages of anesthesia compared to the BIS system.

Background Although bare metal stents (BMS) resolved abrupt closure which was the most important complication of percutaneous coronary balloon angioplasty, and then drug-eluting stents (DES) significantly reduced the rate of restenosis that was seen in around 30% to 40% at mid-term of post-percutaneous coronary intervention (PCI), but stent thrombosis is still a major problem which occurs in different phases. This study was conducted to evaluate the rate of acute complications, especially acute stent thrombosis (in the first 24 hours) in patients who received either BMS or DES. Methods This retrospective study was performed on 1674 patients (640 women and 1034 men) who underwent PCI with at least one stent (from 2002 until 2006). 2404 stents were deployed, 975 BMS (40%) and 1429 DES (60%), (820 Cypher, 570 Taxus and 39 other kinds). 705 stents (35%) were deployed directly and 1699 stents (65%) followed pre-dilatation. Results In 35 cases (2%), the procedure was not completed because of several reasons (failure of guiding catheter engagement, failure to cross the lesions by guidewires or balloon catheters). Fourteen patients (0.8%) suffered acute stent thrombosis (eight in the DES and six in the BMS groups), one of whom was referred for emergency coronary bypass surgery (CABG) and twelve patients treated by re-PCI. One patient was complicated by embolic occlusion of a dominant LCX during manipulation of the guiding catheter that was referred to emergency CABG. Two patients suffered left main (LM) dissection, one of whom was treated by prompt stenting and the other after stabilizing by LM stenting, was referred for urgent CABG. Fifteen cases (0.8%) developed slow or no-reflow phenomenon (six cases in the BMS and nine cases in the DES groups) who were managed by medical and mechanical intervention. Twenty five cases (1.5%) had mild CPK-MB rising (ten patients in the BMS and fifteen patients in the DES groups). Totally 0.3% of cases were referred for emergency or urgent and (1.7%) for elective CABG. Fortunately there was no in-hospital death. Conclusions This study showed a low and similar incidence of acute complications, especially acute stent thrombosis, in PCI in both BMS and DES groups.

Background Sufficient analgesia after coronary artery bypass graft surgery (CABG) is important to prevent postoperative complications. One of these analgesic techniques is patientcontrolled analgesia (PCA), in which the patient has self–controlled administration of anesthetics. The purpose of this study was to evaluate the analgesic effect and side effects of tramadol used with ketamine or morphine for post-CABG surgery analgesia. Methods In this prospective, controlled randomized study, we selected 150 patients who were candidates for CABG. The inclusion criteria were adult patients aged 30-60 with coronary artery disease, candidates for CABG, elective surgery, surgery using cardiopulmonary bypass, and ASA II and III. The patients with uncontrolled and significant underlying diseases (diabetes, liver and kidney disease and clotting disorders), excessive obesity and weight over 115 kg, and non-consenting patients were excluded. The patients were divided into three groups of 50 each. At the end of surgery, all the patients were transferred to the post-surgical intensive care unit, where they were extubated. PCA was commenced when the patients were able to communicate. The first group was provided with 100mg of tramadol with normal saline, the second group 50mg of tramadol plus 20mg of morphine, and the third group 50mg of tramadol plus 50mg of ketamine. During the use of the PCA pump, the patients were observed for respiratory depression (respiratory rate and SPO2, PaCO2 every two hours during the first 8 hours and then every 4 hours). The severity of pain was evaluated with the visual analog scale (VAS) method, where zero was no pain and ten was severe pain. The VAS results were recorded 1, 3, 6, 12, 18, 24, 36, and 48 hours after awareness and extubation and recording the base VAS of the patients. Results The average respiratory rate was 14 in all the three groups and respiratory depression was not seen in any of them. At the third hour, the VAS was similar in all the groups (p value<0.05). The decrease in VAS at 6, 12, and 18 hours was significant and the minimum VAS was seen in the second group (tramadol + morphine). Conclusions PCA is a safe and appropriate method for analgesia after CABG. It seems that the combination of tramadol plus morphine can be an effective solution for analgesia after CABG with fewer respiratory complications than other combinations.

Background Hemodynamic stability in patients after coronary artery bypass graft surgery (CABG) with the cardiopulmonary bypass pump (CPB), especially during transfer to ICU ward and the early hours of ICU admission is very important. Adequate fluid therapy and intravascular volume maintenance as a matter of principle is essential using various intravenous fluids, but there is always the question of what is the ideal intravenous fluid? The aim of this study is to compare the effects of gelatin, hydroxyethyl starch (HES 6%, Voluven), and Ringer’s solution to maintain hemodynamic status after cardiopulmonary bypass in patients undergoing coronary artery bypass surgery. Methods In this randomized double blind clinical trial, 92 patients who were candidates for onpump CABG were studied. After discontinuation of CPB, all patients were transferred to the ICU and were put randomly into three groups. The first group received Ringer’s solution, the second group gelatin 4%, and the third group HES 6% (Voluven). Hemodynamic parameters like heart rate, mean arterial pressure, systolic blood pressure, diastolic blood pressure, central venous pressure, cardiac output and the presence of arrhythmias were documented. Results The volume that was needed for maintaining normal blood pressure and central venous pressure (CVP) in the range of 10 to 14 mmHg was less in the HES group than the other groups, but was similar in the gelatin 4% and Ringer’s groups in the first 24-hours after surgery. Urinary output in the first four hours and 24 hours after surgery were significantly higher in the HES group than the other two groups, and mean creatinine levels were significantly lower in the HES group. Conclusions HES 6% has better volume-expanding effects than gelatin 4% and Ringer’s solution and its short-term effects on renal function are also better.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly accounting for approximately 0.25% - 0.5% of all congenital heart diseases. The blood supply to the left ventricular myocardium is severely compromised and results in myocardial ischemia, infarction, and fibrosis. Here we report a 2-year-old female infant with the ALCAPA, who presented as dilated cardiomyopathy at the first visit.

A 19-year-old man presented with atypical chest pain, history of flu-like symptoms for the previous 14 days, and a rise in cardiac enzymes. His electrocardiogram revealed inferolateral ST elevation with mild PR depression. Cardiac MRI demonstrated focal myocarditis following his viral illness.

A 27-year-old man presented with exertional dyspnea and productive cough as well as weight gain. Transthoracic echocardiography revealed severe right ventricular enlargement with moderate systolic dysfunction and a large right atrial mass protruding into the right ventricular cavity with severe functional tricuspid stenosis. An urgent surgical operation was done, and the tumor was totally excised. The histological findings were those of a biphasic tumor, consistent with synovial sarcoma. This was also confirmed by an immunohistochemistry panel. The patient's chest CT scan showed multiple small peripheral nodules, suggestive of lung metastases. Chemotherapy was administered and several months afterwards, the patient was asymptomatic with no residual mass on echocardiography.

We present a 16-year-old male whose chief complaints were exertional dyspnea, atypical chest pain, and a weight loss of about 5 kg of recent onset. His past medical history and laboratory tests were unremarkable. Echocardiography showed a calcified and mobile mass with irregular borders, measuring 3×2 cm in the left atrium. Grossly, the specimen was creamy-yellow and fragmented with a firm to hard consistency. Microscopically, multiple calcium deposits were seen within a dense background of fibrocollagenous tissue. Based on these findings, a diagnosis of cardiac calcified amorphous tumor (CAT) was made.