Iranian Heart Journal
Volume:12 Issue: 1, Spring 2011

Background Narcotics are the most common drugs used after cardiac surgery and their side effects, including respiratory depression, hemodynamic instability, nausea and vomiting, and itching are dose dependent. Magnesium is both an N Methyl D Aspartate (NMDA)–receptor and a calcium-receptor antagonist and can modify the important mechanisms of nociception. The purpose of this study was to investigate the effect of magnesium sulfate on the pain score and reducing narcotic requirement in coronary artery bypass grafting surgery (CABG) patients. Methods This randomized, double blinded, placebo-controlled trial recruited 185 patients (105 male and 80 female) undergoing elective CABG. Mean age was 58±11 years (range= 24 to 79 years). The patients were divided into two groups randomly: Group 1 received magnesium sulfate as an IV infusion (80 mg/kg) during a one-hour period post induction and Group 2 received the same volume of normal saline as a placebo. During the postoperative period, the patients’ morphine requirement and pain score (visual analogue scale= scaled as 0 to 10, 0=no pain and 10= worst possible pain) at 6th, 12th, 18th, and 24th hours were recorded and documented. Results There were no significant differences between the two groups with respect to the baseline data. In the magnesium sulfate group, only 30 (32%) patients needed morphine sulfate, whereas 75 (83%) patients in the placebo group required some doses of morphine sulfate (p value < 0.001). The odds ratio showed that magnesium sulfate could strongly prevent the need for opioid analgesics for pain control. Conclusions The intraoperative use of magnesium sulfate can reduce the need for opioids post CABG

Background Long-segment reconstruction of the diffusely diseased left anterior descending artery (LAD) with left internal thoracic artery (LITA) is one of the methods offered in order to deal with complicated, multiple, and long-segment lesions in the LAD. In this prospective study, we analyzed the results obtained with this technique. Methods Between Feb. 2007 and Feb. 2009, 56 patients underwent surgery via this technique. The LITA was used as a patch along the opened narrow segment of the LAD from 2 to 8 cm. Data on all the patients were collected, and all the patients were worked up for postoperative complications such as postoperative myocardial infarction, ECG changes, NIHA class, enzymatic changes, and postoperative bleeding. CT-Angiography was performed between 6 to 18 months after surgery in some cases. Results Fifty-six cases, comprising 42 (75%) men and 14 (25%) women between 43 and 78 years of age (mean age= 59.8±9.3 years) with multiple and long-segment lesions in the LAD were included in this study. Preoperative risk factors were hypertension (66.1%), diabetes (57.1%), hyperlipidemia (50%), cigarette smoking (50%), renal failure (1.8%), and positive family history (7.1%). Twenty-three (41.1%) patients had remote and 9 (16.1%) had recent myocardial infarction. Significant left main lesions were found in 7 (12.5%) patients, peripheral vascular disease in 3 (5.3%), and preoperative arrhythmias in 2 (3.6%). The mean number of grafts was 2.85 ±1.5. Postoperative complications were arrhythmias in 10 (17.8%) patients, postoperative myocardial infarction in 1 (1.8%), surgical bleeding in 7 (12.5%), infections in 3 (5.3%), plural effusion in 3 (5.3%), tamponade in 2 (3.6%), and pericardial effusion in 1 (1.8%); there was no mortality amongst the patients. CT-angiography, performed in 6 patients between the six and eighteenth postoperative months, revealed patent anastomoses in all the patients. Conclusions Long segment and multiple lesions in the LAD pose a challenge for cardiac surgeons. The results of longsegment LAD reconstruction using the LITA are very encouraging

Aims Hyperhomocysteinemia has recently been identified as a risk for coronary artery disease (CAD). Some genetic variants such as C677T polymorphism are postulated in this regard. We studied the relation between hyperhomocysteinemia and the above genetic variant and the risk of CAD and also the number of involved vessels. Methods In total, there were 90 patients: 45 with angiographically documented CAD and 45 with the clinical manifestations of CAD but negative angiography. The blood homocystein level was measured using the ELISA and C677T polymorphism using the PCR method. Results The homocystein level was significantly higher in the case group (p value=0.00), but it did not show any correlation between its level and the extent of CAD. The case group was more homozygote in C677T allele but again it had no relation to the extent of CAD. Conclusions Hyperhomocysteinemia acts as a CAD risk factor and whilst its presence increases the risk, it does not predict the extent of it.

Background Given the importance of the effect of muscle relaxants on the extubation time in coronary artery bypass grafting (CABG) patients, we sought to assess the difference in “time to extubation” and “intensive care unit (ICU) length of stay” between the primary bolus doses of Pancuronium and Cisatracurium without using the maintenance dose of them during surgery. Methods This double blind clinical trial divided 110 patients into two equal groups receiving either Cisatracurium or Pancuronium. The patients’ surgical and cardiopulmonary bypass variables were evaluated, and the extubation time and ICU length of stay were compared between the two groups. Results There was no difference between the two groups regarding the depth of anesthesia, train-offour (TOF) scores at the beginning of anesthesia, and the surgical and cardiopulmonary bypass variables. However, the Cisatracurium patients were extubated earlier and had a shorter ICU length of stay than the Pancuronium patients. Conclusions An appropriate depth of anesthesia facilitates the administration of the induction dose of Cisatracurium, which confers earlier extubation and shorter ICU length of stay by comparison with Pancuronium.

Objectives This study evaluated the incidence and predictors of CK-MB and troponin elevation after successful coronary intervention. Background CK-MB and troponin elevation after coronary intervention correlate with late cardiac events and survival.1,2,19,24 We investigated the incidence and predictors of CK-MB and troponin elevation in patients who underwent percutaneous coronary intervention in Rajaie Cardiovascular, Medical and Research Center. Methods CK-MB and troponin elevation was detectable in 203 (70%) patients. Predictors of cardiac enzyme elevation were hyperlipidemia, functional class, and smoking. There were no in-hospital adverse events in the CK-MB and troponin elevation group. Conclusions Cardiac enzyme elevation after coronary intervention was detected in 70% of all our patients and was more common in diffuse atherosclerosis hyperlipidemia, smoking, and high functional class. Enzyme elevation was observed even in the absence of discernible procedural complications, and early discharge of patients with CK-MB and troponin elevation is safe. Midterm survival of patients with CK-MB and or troponin elevation was similar to those with normal enzymes (Iranian Heart Journal 2011; 12 (1):27 -34).

Introduction Paravertebral block is a technique of regional anesthesia and is used for a number of purposes. The aim of this study was to assess the effects of adjuvant neostigmine in paravertebral block with bupivacaine for in coronary artery bypass grafting surgery (CABG). Methods In total, 68 patients were randomly assigned into two groups: bupivacaine alone (B group) and bupivacaine with neostigmine (BN group) for bilateral paravertebral thoracic block at T6 level. Postoperative times for extubation, morphine requirements, and acute pain scores were assessed. Results The BN group patients were extubated sooner. Also, they needed less morphine in the first twenty-four hours. Discussion The study suggests that adding neostigmine to bupivacaine in paravertebral block as an adjuvant can have beneficial postoperative effects in patients undergoing elective CABG.

Background Cardiovascular operations are associated with an inherent bleeding tendency that sometime leads to severe bleeding and transfusion requirement. Pharmacologic intervention to minimize post-bypass bleeding and blood product transfusions has received increasing attention for both medical and economic perspectives. Methods In this double-blind, randomized, placebo-controlled clinical trial, three groups of patients, each comprising 50 patients undergoing on-pump coronary artery bypass grafting surgery (CABG) were blindly randomized to receive either low aprotinin, tranexamic acid, or placebo; the results were subsequently evaluated and compared between the groups. Results The following variables were similar in the groups, and there were no statistically significant differences in these variables: age (p value=0.308), sex (p value=0.973), hyperlipidemia (p value=0.720), hypertension (p value=0.786), smoking (p value=0.72), and diabetes (p value=0.960). The amounts of drainage from chest tubes were less in the aprotinin and tranexamic acid groups compared to the placebo group, and this was statistically significant (p value<0.001). There was no statistically significant difference in need for reoperation for bleeding between the three groups (p value=0.998). Complications following surgery in the three groups were statistically the same and not significantly different (Table below). All the complications had a good course, and all the patients were discharged from hospital uneventfully. There was no mortality in any group. Conclusions Low-dose aprotinin and tranexamic acid can significantly reduce blood loss and transfusion requirement in CABG without importantly increasing mortality and morbidity.

Acute cardiovascular pathology is the most common causes of death and invalidism in a modern society, among acute disturbance of coronary circulation-acute myocardial infarction (AMI) occupies the leading place. The most important in treatment of patients with ST elevation AMI (STEAMI) at which in 95% of cases is observed full thrombotic occlusion of coronary artery, is restoration of adequate blood flow in arteries and steady maintenance of its tissue perfusion. As known, restoration of an adequate blood flow in infarct-related coronary artery (IRA) by drug management or mechanical way reduces the size of myocardium necrosis, promotes conservation of functional condition of heart, reduces hospital mortality and invalidism in the remote period of observation.1-6 Carrying out of emergency PTCA and stenting in early terms of disease provides sufficient blood flow current in the IRA, it limits necrosis zone and prevents development of dilatation and dysfunction of LV.2, 8 Last decade numerous researches are carried out and results of the registers comparing efficiency of thrombolytic therapy (?L?) and PTCA at STEAMI are analyzed. As a result of comparison of medicamentous and invasive methods of coronary blood flow restoration researchers have come to conclusion that it is necessary to restore coronary blood flow by any accessible way as soon as possible. From the aforesaid the exclusive role of time in successful treatment of patients STEAMI becomes clear. Aims The aim of our work was in a study of clinical efficiency of PTCA and stenting of the IRA in various terms from the symptoms beginning by the retrospective analysis of results of treatment the patients STEAMI.

Report Over a five-year period, we encountered two cases of malignant melanoma with metastasis to the heart and pericardium. Both patients had a relevant medical history, showing their previous involvement by this tumor. A high index of suspicion, simply provided by a precise clinical history, together with histopathological and cytological studies can be used to diagnose such patients in due course. The preliminary diagnosis is made by echocardiography, by which the tumoral masses are seen in different parts of the heart. Nevertheless, their primary or secondary origin as well as the histogenesis can only be ascertained by pathological studies. Routine staining methods are useful in the demonstration of malignant cells in the tissue or pericardial fluid samples.

Case Report We describe the case of a 47-year-old woman with a history of sternotomy and insertion of a sternal prosthesis six months prior to admission due to sternal chondrosarcoma. The patient was admitted with dyspnea and chest discomfort, which had increased twenty days before admission. Echocardiography showed moderate pericardial effusion with moderate right ventricular enlargement and dysfunction and large gelatinous mass in the right atrium, which had protruded to the right ventricle through the inflow valve. Unfortunately, the patient died before any intervention. Final echocardiography revealed a reduction in the size of the mass, confirming that the patient’s death occurred secondary to metastatic pulmonary emboli.

Report We report the fracture of a 4×4 Nit-Occlud pfm coil in a child with patent ductus arteriosus (PDA), bicuspid aortic valve, and coarctation, detected three years after deployment without any adverse consequent. This report emphasizes the importance of adherence to the user guidelines of the company for the implementation of the device and also shows the significance of lateral chest X-ray in the follow-up of patients after the occlusion of the PDA, particularly in the case of using smallersized, frail pfm coils for the detection of coil fracture.

Report Kawasaki disease occurs across the globe, with Asians being at the highest risk. Approximately, 20% of untreated patients develop coronary artery abnormalities, including aneurysms, and severely affected patients are likely to develop coronary artery thrombosis or stenosis, myocardial infarction, aneurysm rupture, and sudden death.1 We herein report the case of a 6-year-old boy who developed giant coronary aneurysms, thrombosis, and massive anterolateral myocardial infarction despite appropriate treatment for Kawasaki disease, which make this patient a special case.

Report We present a rare case of hereditary spherocytosis (HS) with intraoperative hemolysis. A 60-yearold man with coronary artery disease, HS, and a history of splenectomy for HS and underwent coronary artery bypass graft surgery under cardiopulmonary bypass, during which he developed severe hematuria and hemolysis and his hemoglobin reached 5g/dL.