The Journal of Tehran University Heart Center
Volume:4 Issue: 1, Jan 2009

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study.

Due to the positive relation between platelet size and platelet reactivity, a high value of the mean platelet volume (MPV) is an independent risk factor to predict acute myocardial infarction (AMI) and its adverse outcome. Few data are available to determinate the prognostic value of MPV in ST-elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention (PCI). The primary purpose of this study was to evaluate the clinical value of MPV to predict impaired reperfusion and in-hospital major adverse cardiovascular events (MACE) in acute STEMI treated with primary PCI. This study included 203 STEMI patients referring for blood sampling before primary PCI to estimate MPV and determine the thrombolysis in myocardial infarction (TIMI) flow grade, corrected TIMI frame count (CTFC), and in-hospital MACE. The frequency of in-hospital MACE in the group of patients with a high MPV (≥10.3 ng/dl) was significantly more than that of the group with a low MPV (<10.3 ng/dl) (37.8% vs. 4.4%, P<0.001). The no-reflow phenomenon was more frequent in the patients with a high MPV than that of the patients with a low MPV (17.8% vs. 1.9%, P<0.001). The mean MPV in the group of patients with CTFC≥40 was significantly more than that of the group of patients with CTFC<40 (10.9±0.92 vs. 9.45±0.85, P=0.001). After adjustment for baseline characteristics, a high MPV remained a strong independent factor to predict the no-reflow phenomenon (Odds Ratio [OR]=2.263, 95% Confidence Interval [CI]=1.47 to 5.97; P<0.002), in-hospital MACE (OR=2.49, 95% CI=1.34 to 4.61; P<0.004), and CTFC≥40 (OR=2.09, 95% CI=1.22 to 3.39; P<0.003). These findings confirmed that not only could admission MPV predict impaired reperfusion and in-hospital MACE in acute STEMI patients treated with PCI, but also it could be considered a practical way to determine higher-risk patients.

We sought to determine the frequency of the risk factors for congestive cardiac failure (CCF) in a tertiary care hospital in Peshawar, Pakistan. This retrospective, observational study was conducted in the department of cardiology, Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from March 2005 to September 2007. Relevant information regarding the risk factors of CCF was recorded on questionnaires, devised in accordance with the objectives of the study. This study recruited 1019 patients with an established diagnosis of CCF on the basis of clinical findings and pertinent investigations. The study population comprised 583 (57.12%) men and 436 (42.78%) women. The patients’ age ranged from 6 years to 82 years with a mean age of 48.5 years and a mode of age of 45 years. The distribution of the causative factors of CCF was as follows: ischemic heart disease in 38.56%; hypertension in 26.30%; dilated cardiomyopathies in 10.10%; obstructive and restrictive cardiomyopathies in 5.39%; valvular heart diseases in 9.32%; congenital heart diseases like ventricular septal defects and atrial septal defects in 4.41% and 0.58%, respectively; constrictive pericarditis in 1.07%; pericardial effusion in 0.68%; chronic obstructive pulmonary disease and pulmonary hypertension in 1.47%; thyrotoxicosis in 0.68%; complete heart block in 0.29%; and Paget’s disease in 0.09% of the cases. Ischemic heart disease, hypertension, cardiomyopathy, valvular heart disease, and congenital heart disease were the major contributors to CCF in our patients.

We sought to evaluate the efficacy and safety of the different trade forms of streptokinase available in our country, namely Heberkinasa (Heberbiotec, Havana, Cuba) and Streptase (Aventis Behring GmbH, Marburg, Germany). We conducted a double-blind randomized clinical trial to compare the two streptokinase formulations, i.e. Heberkinasa (HBK) or Streptase (STP), in patients with acute myocardial infarction who needed thrombolysis. Thrombolysis success was evaluated angiographically and/or clinically. Clinical follow-up was done 30 days after thrombolysis. We randomly allocated 221 patients with a mean age of 56.9±10.8 years (males: 88.2%) to HBK (n=119) and STP (n=102) groups. Baseline clinical and demographic characteristics were similar between the two groups, and the two groups were not significantly different in terms of door-to-needle and pain-to-needle intervals. The rate of complications was not significantly different between the groups (44.1% [HBK] vs. 42% [STP]). Angiography was done for 158 (71.5 %) patients in the first 24 hours (9%) and in the first 72 hours (38.8%) after thrombolysis. Lesion morphology and lesion/patient ratio were not significantly different between the two groups (1.87[HBK] vs. 1.67[STP]). The two groups were similar with respect to angiographic patency rate (67.5% [HBK] vs. 67.6% [STP]). The study groups were also similar as regards clinical outcome and complications of both streptokinase formulations. The present study demonstrated that Heberkinasa is as effective and as safe as a standard streptokinase, namely Streptase, in a clinical setting.

New-onset atrial fibrillation (AF) after cardiac surgery contributes to increased morbidity, hospital length of stay, and resource utilization. Although many aspects of AF after cardiac surgery have already been elucidated, the mechanism by which cardiac surgery predisposes patients to AF has hitherto remained unknown. Recent evidence supports the notion that blood transfusion enhances the inflammatory response, thereby increasing the incidence of post-operative AF. This retrospective study was conducted on 2095 patients who underwent coronary artery bypass grafting (CABG) alone or accompanied by valve surgery between January 2005 and July 2007. Variables associated with the development of new-onset AF were identified using logistic regression. Intensive care unit blood transfusion increased the risk of AF (odds ratio per unit transfused, 1.16; 95% confidence limits, 1.14, 1.24; P<0.001). Blood transfusion was performed in 487 patients and was associated with a significant increase in new-onset of AF (45.9% vs. 37.9%; P<0.01). Homologous blood transfusion can increase the incidence of new-onset AF after CABG. This factor should be considered in identifying patients who might benefit from prophylaxis in order to prevent this common post-operative complication and the adverse consequences thereof.

The aim of this study was to evaluate the impact of diabetes mellitus (DM) on peripheral vascular disease (PVD) in patients with coronary artery disease (CAD). A total of 13702 consecutive patients who underwent coronary artery bypass grafting (CABG) at Tehran Heart Center between January 2002 and March 2007 were included in this study. The demographic data, PVD, and outcome of these patients were reviewed. CABG patients before surgery were detected for PVD (stenosis ≥70% in the abdominal aorta; renal, carotid, and iliac arteries; or any other peripheral vascular system) with physical examination and past medical history. The suspected cases of PVD were, thereafter, confirmed via Doppler sonography or invasive angiography. This study recruited 4344 diabetic patients (mean age 59.30±8.7 years) and 9358 non-diabetic patients (mean age 58.42±9.9 years). The diabetics were significantly older and had a higher incidence of PVD (2.7% vs. 1.8%), female gender, hypertension, renal failure, smoking, and dyslipidemia than the non-diabetics (P<0.05). There was no significant difference between the two groups with regard to family history and left main disease. Also, the mean ejection fraction (EF) was 48.85%±10.4 and 49.35%±10. In the patients with and without DM, respectively; and the difference was significant (P=0.008). The in-hospital mortality rate (mortality over a 30-day post-operative period) was 1.8% in the diabetics and 0.7% in the non-diabetics (P<0.001). In the multivariate analysis, PVD, left main disease, age, female gender, and EF were significant in the development of mortality amongst the diabetic patients with a respective odds ratio of 4.17, 5.54, 1.03, 2.86, and 0.95 (P≤0.050). In the multivariate logistic regression analysis, PVD was significantly higher in the diabetics than in those without DM (OR=1.283, 95% CI: 1.001- 1.644; P=0.049). In the diabetic patients, carotid (1.13% vs. 0.83%), subclavian (0.05% vs. 0.02%), femoral (0.18% vs. 0.09%), renal (0.62% vs. 0.25%), and tibialis (0.16% vs. 0.06%) arteries had a higher incidence of stenosis than those in the non-diabetics. We conclude that in diabetic patients with concomitant CAD, special attention must be directed towards the diagnosis of PVD using physical examination, Doppler sonography; and where needed, CT-angiography or invasive angiography. Also, in risk assessment, the presence of PVD should be strongly considered for CAD patients.

Primary percutaneous coronary intervention (primary PCI) is the method of choice in establishing reperfusion in acute myocardial infarction (AMI) patients. The aim of this study was to determine the success rate of primary PCI in a university medical center in Iran with a view to promoting it as a first-line therapy in patients with AMI, especially in centers with established catheterization labs across the country. All cases of AMI admitted between September 2001 and September 2005 underwent primary PCI. The achieved thrombolysis in myocardial infarction (TIMI) flow was recorded, and the patients were followed during the hospital admission for major adverse cardiac events (MACE). A total of 180 patients, consisting of 36 females and 144 males, with a mean age of 56±2.1 years were included in the study. The target vessel was the left anterior descending artery in 66.1%, right coronary artery in 27.2%, and left circumflex artery in 6.7% of the cases. The respective rate of anatomical and procedural success was 94.4% and 90%. The rates of mortality, coronary artery bypass grafting (CABG), and reinfarction were 6.7%, 1.1%, and 2.2%, respectively. Most patients were discharged with no complications in less than a week. Anatomical success in patients <65 years old was 95% versus 92.5% for those ³ 65 years of age. Procedural success in patients <65 years of age was 93.6% versus 77.5% for those ³65 years old (P<0.05). No significant relation was detected between the success rate and sex, target vessel, or major coronary artery disease risk factors. More patients in the mortality group had a longer door-to-balloon (DTB) time compared to the surviving group (P<0.05). In light of the results of this study, primary PCI may also be practiced as the therapy of choice for AMI patients in centers with established equipment in our region with acceptable rates of MACE and complications. Better procedural success rates are achieved in younger patients and in those with a shorter DTB time.

A 22-year-old man presented with exertional dyspnea commencing one month prior to his admission. Echocardiography revealed a non-homogenous mass, and the pathology examination of the pericardial biopsy was compatible with angiosarcoma.

Severe coronary artery disease often coexists with peripheral vascular atherosclerosis. The assessment of the supra-aortic circulation is, therefore, of clinical relevance. We herein describe a case of coronary artery disease treated with surgical revascularization using the internal mammary artery and thereafter the progressive atherosclerotic disease of the native coronary arteries as well as the left subclavian and left renal arteries.We also describe and discuss the clinical presentation, the diagnostic procedures, and the therapeutic approach with respect to the percutaneous transluminal angioplasty of the subclavian, renal, and right coronary arteries.