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

Acute aortic dissection (AAD) is the most frequent catastrophic event of the aorta; it occurs nearly three times as frequently as the rupture of abdominal aortic aneurysm. Sixty percent of dissection cases are classified as proximal or type A and 40% as distal or type B, according to the Stanford Classification. The most frequent causes of death in acute type B dissection are aortic rupture and malperfusion syndrome.We herein review recent data suggesting different management modalities of type B aortic dissection, including medical, surgical, and endovascular treatments. Although medical therapy is still the standard approach in uncomplicated cases, there are subgroups of patients who may benefit from endovascular management. Endovascular techniques or surgery are valuable options for complicated cases. Hybrid suites, multidisciplinary approaches, and good imaging techniques can be considered as the key to success in this regard.

Early clinical and retrospective angiographic evaluations indicated that in patients with acute myocardial infarction (MI), vulnerable plaques most often represented a mild luminal stenosis. More recent studies drawing upon prospective angiograms, however, have demonstrated that in majority of patients with acute MI, the underlying stenosis is significant. Twenty-eight patients with acute MI candidated for thrombectomy were enrolled in this study. Thrombectomy was performed using export thrombectomy catheters. After the injection of nitroglycerin, the severity of the lesions was determined by two independent operators. Between April 2007 and February 2008, 28 patients, comprised of 26 men and 2 women with acute MI, were evaluated. The underlying stenosis severity was ≥50% in 22 (78.6%) patients and <50% in the remaining 6 (20.4%) patients (P-value <0.01). The right coronary artery was the most common vessel involved in the lesions <50%. Contrary to the general belief of many cardiologists, the majority cases of myocardial infarction occur in consequence of significant stenoses.

Moderate non-organic tricuspid regurgitation (TR) concomitant with coronary artery disease is not uncommon. Whether or not TR improves after pure coronary artery bypass grafting (CABG), however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. This study recruited 50 patients (40% female, mean age: 65.38±8.01 years, mean left ventricular ejection fraction (LVEF): 45.74±13.05%) with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure (PAPs)>30mmHg and LVEF<50% were considered elevated PAPs (EPAPs) and LV systolic dysfunction, respectively. Presence of Q-wave in leads II, III, and aVF was considered inferior myocardial infarction (inf. MI). Pre-operatively, 81.5% of the patients had EPAPs, 16% right ventricle (RV) dilation, and 50% left ventricle (LV) and 16% RV systolic dysfunction. TR severity improved in 64% after CABG, whereas it remained unchanged or even worsened in others (P value<0.001). Patients with inf. MI showed no improvement in TR, while patients without inf. MI had significant TR regression after CABG (P value=0.050). Improvement of TR severity after CABG was not related to pre-operative RV size and function, LV systolic function, or PAPs reduction. Although TR severity decreased remarkably after isolated CABG, a considerable number of the patients had no TR regression. In addition, only absence of inf. MI was significantly correlated to TR improvement after CABG. Further prospective studies with long-term follow-up are needed to determine the other factors predicting TR regression after isolated CABG.

Dilated cardiomyopathy (DCMP) is a myocardial disease characterized by dilated left ventricle or both ventricles and reduced contractility of the myocardium. In patients suffering from DCMP, the serum level of uric acid may increase. This research was designed to evaluate the effect of the serum level of uric acid on systolic and diastolic functions in patients with DCMP. This case-control study was performed on 30 patients with DCMP aged between 1 month and 12 years who were consistent with a control group in terms of age and gender. Patients suffering from congenital and acquired cardiac, renal, metabolic, endocrine, musculoskeletal, neurologic, vascular, and hematologic diseases were excluded. After physical examination, chest X-ray, and electrocardiography, systolic and diastolic parameters were measured via echocardiography, and fasting serum uric acid level was measured. The data were analyzed using the t-test and Pearson correlation coefficient. The average age of the patients in the case and control groups was 7.28 and 7.13 years, respectively. There were 15 boys, and the rest were girls. The serum uric acid level in the case and control groups was 6.22 and 3.31 mg/dl, respectively; the difference was statistically significant (P value <0.01). There was a significant correlation between serum uric acid level and left ventricular isovolumic contraction, interventricular septal diameter, left ventricular septal diameter in diastole, and fractional shortening (P value <0.05). In children with DCMP, the serum level of uric acid increases significantly and this increase is significantly correlated with some of left heart echocardiographic parameters. This test is of predictive value for disease progression.

Hypoalbuminemia may be caused by liver disease, nephrotic syndrome, burns, protein-losing entropathy, malnutrition, and metabolic stress. Alterations in albumin in metabolic stress such as cardiac surgery have been previously investigated. We studied serum albumin concentration in children with congenital heart disease and also the association of hypoalbuminemia with mortality and morbidity after pediatric cardiac surgery. We measured serum albumin concentration prospectively in 300 children with congenital heart disease who underwent surgery between July and September 2008 in Shaheed Rajaee hospital. Serum albumin concentration was measured before and 48 hours after cardiac surgery and was subsequently compared between 2 groups: cyanotic and acyanotic and also with normal values. Serum albumin concentration decreased on the second post-operative day in 70 (23.3%) patients. There was a positive correlation between the post-surgical hypoalbuminemia and cyanotic heart disease. The cyanotic children had lower serum albumin concentration than the acyanotic ones (P value <0.001). There was a significant association between post-operative serum albumin concentration and acute renal failure (P value <0.001) and death (P value <0.001). Drop in serum albumin concentration was more prominent in the males than in the females (P value=0.038) and in the cyanotic patients than in the acyanotic ones (P value <0.001) as well as in those with acute renal failure (P value <0.001), pericardial effusion (P value =0.050), seizure (P value <0.001), and death (P value <0.001). Hypoalbuminemia was not associated with longer hospital (P value=0.142) or intensive care unit stay (P value=0.199). Post-operative serum albumin concentration was lower in the cyanotic children and male patients in our study. In addition, the post-operative decrease in albumin was associated with an increased risk of pericardial effusion, renal failure, seizure, and death.

Given the dearth of data in the existing literature on the size and morphologic variability of secundum-type atrial-septal defect (ASD-II) in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophageal echocardiography (TEE). A total of 50 patients (68.0% female) with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of the defect were evaluated, and the largest defect size was measured. The ASD rim was divided into 6 sectors: the superior-anterior, superior-posterior, superior, inferior-anterior, inferior-posterior, and inferior. The minimal length of the defect rims was determined. Mean age at the time of evaluation was 33.62±14.48 years. Mean defect diameter in the all the study patients was 20.80±8.17 mm. Thirteen morphological variations were detected. Deficiency of one rim was detected in 14 (28%) patients, two in 16 (32%), three in 2 (4%), and four in 2 (4%). Deficiency of the superior anterior rim was found in 24% of the patients as the most frequent morphology. There was a significant correlation between the defect size and number of deficient rims (γ=0.558, P-value<0.001). Forty-eight (96%) patients emerged for defect closure: 22 (46.2%) suitable for percutaneous closure and 26 (53.8%) for surgical closure. Two patients with small defects were recommended for medical treatment and follow-up. ASD-II is larger and more morphologically variable in adults than in children. Based on the findings of the present and previous studies and given the advantages of percutaneous treatment, it is advisable to make a decision on ASD-II closure as soon as possible before it outgrows the transcatheter closure suitability criteria.

Cornelia de Lange syndrome (CdLS) is a rare syndrome characterized by multiple congenital anomalies, mental retardation, characteristic facial appearance, developmental delay, skeletal malformation, hirsutism, and various cardiac and ophthalmological problems. The diagnosis of this syndrome is clinical. The patient of the present case report was the second case of CdLS from Iran; only a few cases of CdLS have thus far been reported from countries outside Europe and North America. Reporting CdLS cases of different ethnic backgrounds can add nuances to the phenotypic description of the syndrome and be helpful in diagnosis. Furthermore, an increased awareness of this syndrome may result in an early diagnosis and a decrease in morbidity.

Coronary artery perforation is a rare, but potentially serious, complication of percutaneous coronary intervention and is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Management is different but requires prompt recognition and treatment. We describe a case of coronary perforation only after guidewire removal and also review the management of vessel rupture and perforation.

Tranexamic acid is generally used in the treatment of disorders that predispose one to bleeding. It is a synthetic lysine analog that has strong antifibrinolytic activity. Plasminogen binds to fibrin to form plasmin, which in turn degrades fibrin into fibrin degradation products. Tranexamic acid blocks the lysine binding site on plasminogen and prevents interaction with fibrin. Tranexamic acid reduces blood loss in open heart surgery, hip replacement, and gynecology procedures. In this first case of inadvertent intrathecal injection of Tranexamic acid in a pregnant woman, we found that a massive intrathecal injection of Tranexamic acid triggered refractory ventricular fibrillation and cardiovascular collapse, which did not respond to full resuscitation.