Iranian Heart Journal
Volume:19 Issue: 4, Winter 2018

Clinical supervision is a mutual relationship between a health-care provider and a supervisor and promotes the professional skills of the health-care provider. This study aimed to investigate the effects of the implementation of a clinical supervision model on the level of education provided to cardiac patients. This quasi-experimental study used a before-after design with no control group. A stratified random sampling method was used (N=300). First, the researcher used a data-gathering form to assess the level of education provided to cardiac patients. The clinical supervision model was designed and implemented by the researcher. Using the same form, the researcher re-assessed the level of education given to the cardiac patients and compared the results before and after the implementation of the model. The data were analyzed in the SPSS software, version 19, using descriptive and inferential statistics. The findings showed that after the implementation of the clinical supervision model, the level of education provided by health-care providers significantly increased (P<0.001). The findings also showed that the cardiac patients were satisfied with the received education (P<0.001). A continuous and regular supervision plays a significant role in the implementation of patient education. It is recommended to set management and supervisory programs for health- care providers in order to save the lives of cardiac patients.

A better sternal fixation reduces the attendant risk of superficial and deep infection and enhances postoperative respiratory mechanics, thereby fast-tracking the patient’s recovery and rehabilitation, as well as professional re-ion. The aim of this study was to evaluate the safety and efficacy of Wire-Box Fixation as an alternative technique for sternal closure after median sternotomy. This case-series study was conducted on patients undergoing routine sternal closure after median sternotomy, which was concluded with Wire-Box Fixation. The current method can be executed with a sternal wire number 5 or 7. First, a figure-of-eight (FOE) stitch is placed on the manubrium. Then, a stitch is placed above the inferior loop of the previous one in its hole. It is thereafter exited out above the former wire and turned around downstream (interlocking) to profile the second FOE stitch so as to dress the Louis angle between the manubrium and the sternal body. This procedure is repeated until a total number of 4 to 5 interlocking FOE stitches are placed in proportion to the sternal length. When placing an FOE stitch, care should be taken to stitch perpendicularly and staying trans-sternal to decrease the risk of iatrogenic bleeding. In total, 191 patients at a mean age of 56.0±14.4 years were enrolled. The mean pain score level on the first postoperative day, based on a visual analog pain scale, was reported to be 4.8±2.1, while it was reported to be 2.1±1.4 on the day of discharge. No sternum instability, dehiscence, or revision surgery was reported with the usage of Wire-Box Fixation. An incidence rate of 0.51% was reported for wound infection and 4.1% for death unrelated to wiring. No further complications were reported during a 3-month follow-up. It appears that Wire-Box Fixation is an optimal technique of sternal fixation given its prominent advantages of low cost, rapid installation, and low incidence of complications.

Percutaneous coronary intervention (PCI) with the addition of potent antithrombotic medications is the best therapy recommended for ST-elevation myocardial infarction (STEMI). The prehospital administration of heparin is commonly prescribed in the absence of conclusive data supporting its administration time. We aimed to study the side effects of heparin administration, especially hematoma formation at the arterial access site, between patients who received it before and after femoral arterial access in PCI. This prospectively randomized clinical trial studied 128 patients who were diagnosed with STEMI and candidated for primary PCI at Rajaie Cardiovascular, Medical, and Research Center. Ninety-six patients who fulfilled the inclusion criteria were enrolled and randomly allocated to 2 groups according to a random table. The first group received heparin before the establishment of the femoral arterial access in the catheterization laboratory or in the ambulance (as soon as possible), while the second group received intravenous heparin after arterial access ion for primary PCI. The systemic side effects of heparin and its angiographic appearances were compared between the 2 groups. The administration of unfractionated heparin before femoral arterial access in primary PCI had no more hematoma formation than did heparin injection after femoral arterial access (P=0.03). The study was unable to make any judgments regarding the angiographic thrombus burden before primary PCI according to the time of heparin injection because of the low volume of the patients; nonetheless, there was no significant difference between the 2 groups concerning thrombus burden. Heparin therapy before femoral arterial access in primary PCI had no deleterious effect on hematoma formation.

It is not clear whether the serum uric acid level is independently associated with the long- term incidence of hypertension. The aim of this study was to assess the association between serum uric acid and salt sensitivity in an Iranian normotensive population. This cross-sectional study was conducted at the Cardiovascular Research Institute, Isfahan University of Medical Sciences, July 2014 to October 2014. A group of 140 eligible healthy volunteers aged between 20 and 40 years with a normal blood pressure was enrolled in this study. After the determination of the baseline mean blood pressure and serum uric acid level, salt sensitivity was determined in all the subjects according to a protocol described by Weinberger and Fineberg via the infusion of normal saline and furosemide in 2 consecutive days. Blood pressure was determined before and 2 hours after these interventions. All the data were analyzed using the Student t-test, the χ2 test, and a multiple logistic regression model. The average age of the study population was 25.73±3.35 years, and the mean body mass index was 23.1±2.9 kg/m2. According to the definition for salt sensitivity, 56 (42.7%) of the participants were sensitive and 75 (57.3%) were not sensitive to salt. Thirty-nine (29.8%) of the participants were hyperuricemic, 20 (51.3%) of whom were salt sensitive. Among the normouricemic participants, 49 (53.3%) were salt sensitive. These differences were not statistically significant between the salt-sensitive and salt-insensitive groups (P=0.23). There was no association between hyperuricemia and salt sensitivity even after adjustments were made for the demographic and anthropometric variables (OR=0.70 and 95 CI=0.29 to 1.68). We did not find an association between serum uric acid and salt sensitivity among our young Iranian normotensives.

Although aging is not a disease, a vast portion of the geriatric population all over the world has to deal with various types of cardiovascular diseases such as hypertension (HTN). The current investigation was designed to evaluate the factors involved in fear of falling (FOF) in the elderly population with HTN in Tehran, Iran. The current descriptive-correlative investigation was conducted on an elderly population with HTN who referred to ed teaching hospitals affiliated with Shahid Beheshti University of Medical Sciences between June 2017 and September 2017. The sample ion was performed via the availability method cardiovascular, internal, and nephrology clinics. Data were collected using a demographic questionnaire and the Persian version of the Falls Efficacy Scale-International. The study population comprised 301 patients: 45.2% men and 54.8% women at an average age of 68.62 (±6.82) years. The majority of the patients had low levels of FOF. Also, there was a significant relationship between FOF and gender, occupational status, the income level, the education level, having living companions, living in a hazardous environment, and taking antihypertensives (P˂0.05). Moreover, no meaningful association was observed between FOF and other diseases, a history of hospitalization within the preceding year, and the age of the patients (P˃0.05). According to the obtained data, FOF is ever-present among senior adults. FOF is associated with various factors and variables. Therefore, employing interventional strategies aimed at preventing and reducing the rate of falling or its concern is a critical issue in the caring program for the geriatric population. (Iranian Heart Journal 2018; 19(4): 33-39)

Failing heart has been described as the main mechanism of an unsuccessful separation the mechanical ventilator after cardiac surgery. Brain natriuretic peptide (BNP) is a specific marker for cardiac dysfunction. We aimed to evaluate the relationships between BNP levels and the duration of mechanical ventilation and the length of stay at the intensive care unit (ICU) after pediatric cardiac surgery. In this observational study, 52 infants aged between 2 and 50 months who underwent cardiac surgery were enrolled. Anesthesia and cardiopulmonary bypass methods were similar, and the weaning protocol in the ICU was the same in all the patients. The levels of pro-BNP and plasma lactate were recorded before surgery; at the time of ICU admission; and 24, 48, and 72 hours afterward. At the end of the study, the relationships between the levels of BNP and plasma lactate and the duration of mechanical ventilation and the length of stay at the ICU were assessed. Of the 52 patients, 35 (67.3%) were male. The mean age and weight were 17.14±12.50 months and 9.01±2.98 kg, respectively. The mean duration of cardiopulmonary bypass was 191.25±34.15 minutes, and the mean aortic cross-clamp time was 75.48±31.88 minutes. The mean duration of mechanical ventilation was 21.78±18.78 minutes, and the mean length of stay at the ICU was 133.67±97.68 hours. The results showed that there was no significant relationship between the pro-BNP level and the duration of mechanical ventilation (P>0.05). The levels of pro-BNP at the time of ICU admission and 24 and 48 hours after surgery had a direct relationship with the duration of ICU stay (P<0.05). In the present study, higher serum pro-BNP levels at the time of ICU admission and 24 and 48 hours after admission were related to a prolonged ICU stay. However, the serum BNP level was not correlated with the duration of mechanical ventilation after pediatric cardiac surgery. (Iranian Heart Journal 2018; 19(4): 40-46)

Enoxaparin is known to be a low-molecular-weight heparin used in the treatment of patients with deep vein thrombosis, pulmonary embolism, unstable angina, and acute myocardial infarction. The serum level of anti-factor 10, a biomarker, can be used to assess the anticoagulant effects of noxprin. This clinical quasi-experimental trial recruited patients with a diagnosis of the acute coronary syndrome who were under treatment with adjusted and unadjusted doses of noxprin. Immediately before the administration of the next dose of noxprin, the serum level of activated anti-factor 10 in the patients was measured and compared with the value obtained via a fully automated chromogenic method. The study population was comprised of 107 patients: 68.2% male and 31.8% female. The mean and standard deviation of the patients’ age was 11.13±36.61 years. Based on the study’s inclusion criteria of age and the level of creatinine clearance, 35.5% and 64.5% of the patients received adjusted and unadjusted doses of noxprin. The attainment rate of the appropriate level of active ani-factor10 was 81.2% and 62.6%, respectively, in the patients who received the adjusted and unadjusted doses of noxprin (P=0.364). The adjustment of the dose of noxprin in our patients based on their age and creatinine clearance level increased the attainment level of anti-factor 10.

The congenital absence of the pericardium is a rare cardiac entity which could be manifested in isolation or in association with other anomalies. Usually, affected cases are asymptomatic. Hereby, we describe adults with recent palpitations who were diagnosed with the partial absence of the pericardium on chest computed tomography (CT). The first case was a 49-year-old woman, who presented with palpitations, especially in the left decubitus position, of 1 year’s duration. Her physical examination revealed nothing of significance, except for tachycardia. The second case was a 37-year-old woman, who presented with dyspnea. Transthoracic echocardiography suggested the partial absence of the pericardium. The definite diagnosis was made using multidetector CT, which was compatible with the echocardiography findings. An abnormally leftward rotated heart without a tracheal deviation, an elongated and flattened left ventricular border (Snoopy’s sign), the absence of the pericardium, an excessive cardiac motion, a prominent pulmonary artery, and cardiac pulsations were seen on the scan slices. A lucent area between the diaphragm and the heart or the aorta and the pulmonary artery was also seen due to an interposed lung tissue. The final case was a 40- year-old man, who presented with dyspnea. In addition to the above findings, dextrocardia and a persistent left superior vena cava were noticeable. Palpitations and sinus tachycardia in adults may be a mere presentation of the partial absence of the pericardium, and multimodality imaging can be applied for the proper identification of this entity. (Iranian Heart Journal 2018; 19(4): 54-57)

A 36-year-old man, who had a history of aortic valve replacement 8 years previously because of severe aortic stenosis and bicuspid aortic valve, presented to the emergency department with a hemodynamically unstable ventricular tachycardia. Echocardiography showed an asymmetrical left ventricular hypertrophy and a normal functioning prosthetic valve with a negligible transvalvular gradient and no evidence of patient-prosthetic mismatch. Cardiac magnetic resonance imaging revealed left ventricular hypertrophy with an apical aneurysm, diffuse late gadolinium enhancement, and a midcavitary obstruction, all in favor of hypertrophic cardiomyopathy. Ventricular tachycardia ablation was done via the trans-septal approach, and an implantable cardioverter-defibrillator was ed. (Iranian Heart Journal 2018; 19(4): 58-61)

Primary and secondary cardiac tumors are uncommon, but not extremely rare. Cardiac tumors comprise benign and malignant tumors that arise the heart valves, endocardium, or myocardium. On the other hand, nowadays, infective endocarditis involves increasing numbers of patients without predisposing cardiac conditions and requires a completely different management approach. We describe a challenging case of a cardiac mass (left ventricular apical mass) and present some educational points and discuss the differences between cardiac tumors, infected left ventricular clots (endocarditis), and pure left ventricular apical clots. (Iranian Heart Journal 2018; 19(4): 62-65)