Iranian Heart Journal
Volume:20 Issue: 2, Summer 2019

Transradial coronary arteriography has been developed as the first method of choice for interventional procedures in many centers, and its feasibility and safety contribute to its popularity. Gaining access is the main step in radial artery arteriography. We sought to evaluate the efficacy of the preprocedural administration of papaverine in diminishing arteriography complications. A total of 120 patients were enrolled in the present study. The study population was divided into 2 equal groups of 60 patients. One group was catheterized with the preprocedural administration of papaverine, and the other group was administered traditional TNG. The groups were thereafter compared in terms of the administration of papaverine versus traditional TNG. No significant difference was observed between the 2 groups concerning failure to gain radial access. There was a significant difference in the time to gain access (P=0.016) and in the number of tries to gain access (P=0.007) between the study groups, and both of these values were lower in the papaverine group. Subgroup analysis revealed that the time to gain access was significantly lower in the male patients (P=0.035), younger patients (P=0.008), and smokers (P=0.043). There was also a significant difference in favor of the papaverine administration with respect to the operator’s experience in the low-volume operators. Additionally, a shorter procedure time was observed in the papaverine group, which was more meaningful in the nondiabetic and nonhypertensive cases. The preprocedural administration of papaverine in radial artery angiography confers benefits and could, thus, be a suitable substitution for traditional TNG with a view to diminishing the undesirable consequences of radial artery catheterization. (Iranian Heart Journal 2019; 20(2): 6-12)

Cardiac resynchronization therapy (CRT) has a beneficial effect on clinical symptoms, exercise capacity, and systolic left ventricular (LV) performance in patients with heart failure. The objective of the current study was to evaluate whether a gender difference exists in response to CRT according to clinical indices. Totally, 229 consecutive patients with end-stage heart failure (LV ejection fraction ≤35%), QRS duration >120 ms, and left bundle branch block configuration underwent CRT. At baseline and 6 months post-CRT, clinical and echocardiographic parameters were evaluated and followed-up was obtained for up to 6 months. The clinical alterations after CRT implantation were compared between the men and the women. The study population consisted of 229 patients [129 (56.3%) male and 100 (43.7%) female; mean age=62.90±12.97 y, and age range=9–24]. No significant difference between the men and the women regarding age was found [men=62.13±14.26 y and women=63.89±11.12 y (P=0.3)]. The mean of the QRS width after CRT implantation in the men and the women was 147.50±23.09 and 145±18.45 ms, respectively, and the difference between the 2 groups was significant (P=0.001). There was no significant relationship between sex and hospitalization (P=0.09). At 6 months’ follow-up, LV ejection fraction in the men and the women was 18.56±6.18 and 20.78±8.96, respectively (P=0.1). At 6 months’ follow-up, most of the patients had a normal sinus rhythm. Most of the deaths were seen in the males. The men had a slightly greater QRS width after CRT implantation in than the women. The chief reasons for hospitalization and mortality were shock and heart failure decompensation. LV ejection fraction before and after CRT was significantly greater in the female patients than in their male counterparts; however, the difference was significant before the implantation.

Malnutrition is common among children with cardiovascular diseases. A few studies have been conducted on the relationship between malnutrition and the incidence of postoperative infections among these children. This study sought to evaluate the relationship between malnutrition and nosocomial infections in pediatric patients undergoing cardiac surgery. Totally, 129 children <15 years old who developed nosocomial infections after cardiac surgery were enrolled. According to weight for age, weight for height, and height for age, malnutrition was defined as mild, moderate, and severe. The association between some blood factors such as hemoglobin and hematocrit and malnutrition was also investigated. The prevalence of mild, moderate, and severe malnutrition based on weight for age was 19.5% (n=23), 16.9% (n=20), and 32.2% (n=38), respectively; according to height for age was 15.4% (n=19), 13.8% (n=17), and 20.3% (n=25), respectively; and according to weight for height was 19.4% (n=24), 18.5% (n=23), and 31.5% (n=39), respectively. Pneumonia was significantly associated with moderate and severe malnutrition (P=0.006). Among biochemical indices, only hemoglobin (P=0.007) and hematocrit (P=0.01) were associated with malnutrition in these children. Pneumonia and anemia are associated with malnutrition in children undergoing cardiac surgery and it is necessary to resolve malnutrition before therapeutic processes.

Hepatitis C virus (HCV) infection is prevalent and potentially fatal in patients with cirrhosis and hepatocellular carcinoma. The main routes of transmission are via sharing syringes, blood products, and sexual contact. We sought to determine the incidence of HCV infection among patients with cardiovascular diseases (CVDs) in an 18-month period. During a period of 18 months, 39450 patients with CVDs underwent HCV Ab measurement via the ELISA technique. Hbs Ag was also checked among HCV-positive cases in Rajaie Cardiovascular, Medical, and Research Center in Tehran, Iran 2015 to 2016. The patients were aged between 4 months and 97 years. In 72 out of the 39450 patients (0.18%), HCV Ab was positive and 2 out of the 72 patients (2.7%) were also positive for HBs Ag. The prevalence of HCV infection in patients affected by CVDs in a single referral center in Iran may be lower than that in other groups.

Despite all the focus on systolic blood pressure (SBP), few studies exist on high diastolic blood pressure (DBP) treatment between the different genders. In this study, we investigated the effects of prazosin as an additional treatment for refractory DBP. Totally, 75 nonblack adults were enrolled in this study with primary hypertension and DBP >100 mm Hg as isolated diastolic hypertension or systolic-diastolic hypertension. All the patients were treated with 1 or more drugs the 5 major antihypertensive group drugs (ACE-I, ARB, diuretic, Ca-channel blockers, and beta-blockers). If hypertension did not respond to these drugs, prazosin was added at a mean dose of 1–2 mg (1.6 mg) daily. Many of the patients needed additional low doses of prazosin for the control of DBP. The response of the females was significantly better than that of the males to the 5 major antihypertensive drugs (P=0.001) . This study showed that the 5 major drug groups, albeit conferring good SBP control (25.8% reduction in SBP), in the majority of the patients only caused a 10% decrease in DBP. However, prazosin led to a 21.8% decrease in DBP and a 9.5% decrease in SBP. Consequently, prazosin could be an effective drug in controlling resistant DBP with minimal side effects. Low-dose prazosin as an additional drug to other major antihypertensive drugs with minor and transient complications can be reliably effective in reducing resistant DBP.

Chronic hypertension is one of the most important threats to public health in that it could cause structural and functional myocardial dysfunction, leading to myocardial hypertrophy and fibrosis. The early detection of cardiac remodeling due to hypertension has curative and preventive advantages; in this regard, cardiac magnetic resonance imaging (CMR) is a helpful modality. In this cross-sectional descriptive study. 20 patients with heart failure and no other risk factors, except hypertension, who were referred to the Heart Failure Clinic of Rajaie Cardiovascular, Medical, and research Center between 2015 and 2017 were evaluated with CMR. The left ventricular mass index (LVMI) was normal in 55% and increased in 45% of the patients, and the left ventricular myocardial thickness (LVMT) was normal in 25% and increased in 75%. Twenty-five percent of the patients had normal LVMI and LVMT. Concentric remodeling was observed in 30% of the patients and 45% had concentric hypertrophy. All the patients had an increased LV end-systolic volume index. LV noncompaction without a specific fibrosis pattern was detected in 25% of the patients. Twenty- five percent of the patients had a scattered pattern, possibly due to diffuse interstitial fibrosis. In this study, most of the patients with hypertensive cardiomyopathy were in the normal LVMI/LVMT or cardiac remodeling group and all of them had an increased LV end-systolic volume index. Both of these findings are suggestive of increased wall stress, which could lead to heart failure with a reduced ejection fraction and its progression. (Iranian Heart Journal 2019; 20(2): 40-46)

We sought to evaluate the association between hypertension (HTN) and left ventricular (LV) mechanical synchrony parameters derived via the phase analysis of gated single-photon emission computed tomography (GSPECT) myocardial perfusion imaging (MPI). Ninety-nine patients with no known coronary heart disease (CHD) who underwent GSPECT MPI and had normal resting and post-stress scan with a recent normal echocardiographic examination and a positive history of HTN were recruited. The gated images were analyzed by Cedar–Sinai’s quantitative GSPECT. The global and regional LV mechanical synchrony indices—including phase histogram bandwidth (PHB), phase standard deviation (PSD), and entropy—were derived and compared with the results of the control group, which had previously been defined with the same protocol for a group of 100 patients with a low likelihood for CHD. Comparisons between the study and control groups revealed that neither global nor regional wall-based indices for PHB, PSD, and entropy were significantly different between the 2 groups (P> 0.05), whether or not HTN was accompanied by comorbid diabetes. Congruent with the control group, a significant difference was detected between the global LV phase parameters of the 2 genders (P<0.05). HTN does not intrinsically have a significant impact on the mechanical synchrony indices of GSPECT MPI. (Iranian Heart Journal 2019; 20(2): 47-55)

Gastrointestinal (GI) complications occur after 0.4–2.9% of cardiac surgery procedures. Although infrequent, GI complications constitute some of the most serious complications of cardiac surgery with a high associated morbidity and mortality rate of 14–63%. In this study, we aimed to determine the incidence of and the risk factors for GI complications following open=heart surgery. In this retrospective study, 800 adult patients who underwent valvular surgery, coronary artery bypass grafting (CABG), combined procedures, aortic surgery, and the surgical correction of adult congenital heart defects in Rajaie Cardiovascular, Medical, and Research Center between April 2014 and May 2016 were studied. The clinical data on any GI complication—including its incidence, characteristics, diagnostic measures, mortality, and medical or surgical management—were retrospectively analyzed. Statistical analysis was performed using a non-paired Student t-test and the χ2 test. A total of 800 patients underwent open cardiac surgery: 340 (42.5%) had CABG, 290 (36.3%) had valve surgery, 120 (15%) had combined procedures (valve surgery CABG), 15 (1.9%) had aortic surgery, and 35 (4.3%) had congenital defect correction. Among these patients, GI complications were seen in 36 patients, with an incidence rate of 4.5%. The total mortality rate was 11.1%. Our results revealed that advanced age, a prolonged cardiopulmonary bypass time, prolonged mechanical ventilation, a history of peptic ulcer, and the use of inotropic support or intra-aortic balloon pumps were the risk factors for GI complications after cardiac surgery. GI complications following cardiac surgery have a low incidence rate but high morbidity and mortality rates. Primary detection and prompt appropriate intervention are essential for the outcome of the patients.

Although invasive coronary angiography (CAG) is the gold standard for the diagnosis of coronary artery disease (CAD), myocardial perfusion imaging (MPI) is also used in suspected cases. In this study, we sought to determine the diagnostic value of MPI in the anatomical localization of CAD. In a retrospective study, all patients with an intermediate to high probability of CAD who had positive single-photon emission computed tomography MPI and subsequently underwent CAG between January 2016 and January 2017 were evaluated. A total of 210 patients at a mean age of 60.2±10.6 years underwent MPI and CAG. Abnormal anterior segments in MPI had a positive predictive value (PPV) of 68.1% to detect a diseased left anterior descending artery (LAD), and the negative predictive value (NPV) of similar segments for a concomitant LAD and right coronary artery (RCA) involvement was the highest (90.4%). Abnormal inferior segments in MPI had PPVs of 65.1% and 47% for the LAD and the RCA, respectively. The NPV was 81.8% for a concomitant LAD and RCA involvement and it was greater than either of each alone. Among the patients with abnormal posterior segments, the RCA and the left circumflex artery (LCX) had a PPV of 66.7%, which was greater than that of a concomitant RCA and LCX involvement. The NPV for either RAC or LCX alone or both arteries together was similar. MPI provides a relatively good diagnostic accuracy to detect abnormal segments matched to the involved coronary arteries in CAG. However, diagnostic accuracy was more pronounced in matching single-vessel CAD compared with double-vessel CAD.

Considering the many reports of elevated threshold levels and left ventricular dysfunction in epicardial leads, the evaluation of the short- and long-term efficacy of this type of leads is necessary in comparison with the coronary sinus (CS) leads. The present study compared left ventricular epicardial pacing via surgery and CS pacing in patients with triple- chamber pacemakers. This retrospective cohort study was performed on patients referred for cardiac resynchronization therapy. The patients were re-evaluated with ECG after pacemaker implantation and before discharge. The evaluations were performed in 2 patient groups under left ventricular epicardial pacing and CS pacing. At 12 months’ follow-up, the mean left ventricular pacing lead threshold was significantly higher in the patients with epicardial lead pacing than in those with endocardial lead pacing. Additionally, regarding the ECG pattern after lead pacing, the morphology of QRS at V1 lead and also the type of the QRS axis significantly differed between epicardial pacing and CS pacing 6–12 months after pacemaker implantation. The mean left ventricular pacing lead threshold was at its highest in the posterolateral area and at its lowest in the anterolateral area, but without any significant difference. Comparisons between the results and the long-term effects of CS pacing and surgical epicardial lead pacing in the present study indicated that the increase and changes in the left ventricular leading threshold in the epicardial pacing lead were much more pronounced than those in CS pacing through the CS. Therefore, the use of CS leads might be preferred to pericardial leads due to the stability of left ventricular leads.

Sleep apnea is a common disorder and is known to impact myocardial stress and increase morbidity and mortality. The concentrations of cardiac highly sensitive troponin I (hs-TnI) are currently in clinical use as markers of myocardial injury. That obstructive sleep apnea (OSA) may lead to myocardial injury and elevated cardiac troponin levels suggests that the treatment of sleep apnea with positive airway pressure (PAP) should decrease myocardial injury. We studied 114 patients with a diagnosis of moderate-to-severe OSA who were referred to our cardiovascular department. None of the patients had a history of cardiovascular problems and diabetes. The mean age was 30.653.96 years. The patients were divided into 2 groups: the first group (the O2 group) received nasal O2 for 2 weeks, and the second group (the PAP group) received PAP for about 2 weeks. The concentrations of hs-TnI were measured in evening blood samples in ed patients. After 2 weeks of treatment with O2 or PAP, the serum hs-TnI level was rechecked and compared with the baseline and between the 2 groups. The level of hs-TnI did not differ significantly between the 2 groups. No patients in either O2 or PAP group showed elevated troponin levels before the treatment. The cardiac biomarker, hs- TnI, was detectable (≥1 ng/L) in none of the patients in the O2 group before and after the treatment and only in 2 (3%) patients in the PAP group after treatment. There was no significant difference in the hs-TnI level before and after the treatment with nasal O2 (P=0.4). Although OSA is well known to impact myocardial stress, we did not find increased amounts of cardiac hs-TnI as a biomarker of myocardial damage even in the severe form of OSA. PAP did not cause any myocardial damage detectable with the hs-TnI level and it was somewhat more effective than was O2 in decreasing the baseline level of troponin.

A 48-year-old woman presented to our hospital with exacerbating cyanosis, edema, lethargy, and dyspnea. The patient declared amphetamine usage until 3 days earlier. Her respiratory function deteriorated gradually, resulting in intubation. During the hospitalization course, she became febrile with a positive blood culture due to an infected central venous catheter. Transesophageal echocardiography revealed a normal left ventricular systolic function, severe left ventricular hypertrophy, and a severe pulmonary arterial hypertension. We found multiple ruptured chordae, resulting in a flail mitral valve and severe mitral regurgitation. To the best of our knowledge, this is the first report of multiple ruptured chordae in the setting of amphetamine intoxication. (Iranian Heart Journal 2019; 20(2): 81-84)