The Journal of Tehran University Heart Center
Volume:7 Issue: 4, Oct 2012

A common complication of prosthetic heart valves is thrombosis. Although the incidence of prosthetic valve thrombosis (PVT) in the tricuspid position is high, there are not enough data on the management of it, in contrast to left-sided PVT. Here, we describe three cases of tricuspid PVT with three different management approaches: thrombolytic therapy; close observation with oral anticoagulants; and surgery. The first case was a woman who suffered from recurrent PVT, for which we successfully used Tenecteplase for second and third episodes. We employed Tenecteplase in this case for the first time in the therapy of tricuspid PVT. The second case had fixed leaflets in open position while being symptomless. At six months'' follow-up, with the patient having taken oral anticoagulants, the motion of the leaflets was restricted and she was symptom-free. The last case was a woman who had a large thrombus in the right atrium immediately after mitral and tricuspid valvular replacement. The patient underwent re-replacement surgery and a new biological valve was implanted in the tricuspid position. Also, we review the literature on the pathology, signs and symptoms, diagnosis, and management of tricuspid PVT.

Pregnant women with previous gestational diabetes mellitus are at increased risk of progressive carotid artery disorders. The current study evaluated carotid intima-media thickness (IMT) in pregnant women with gestational diabetes at two time points of mid-term and full-term pregnancy to determine whether gestational diabetes mellitus causes increased IMT. This cross-sectional study carried out at Afzalipour Hospital (Kerman, Iran) between 2009 and 2010, recruited 50 women who were at high risk of gestational diabetes during pregnancy and had an oral glucose challenge test (OGCT) as screening for gestational diabetes. B-mode ultrasound scans were performed at baseline and at two time points of mid-term pregnancy (20 to 24 weeks) and full-term pregnancy (36 to 38 weeks) on all the participants. The mean IMT of common carotids and internal carotid arteries from two walls (near and far walls) at four different angles was assessed. An overall comparison between the impaired OGCT test group and the control group revealed significant differences in carotid IMT in the mid-term (0.65 ± 0.07 vs. 0.59 ± 0.06 mm; p value = 0.002) and full-term (0.65 ± 0.05 vs. 0.59 ± 0.04 mm; p value < 0.001) pregnancy; however, the trend of the changes in carotid IMT during mid to full-term pregnancy was insignificant in each group (p value > 0.05). Carotid IMT was significantly higher in the women with gestational diabetes than that in the normoglycemic group in different trimesters. This finding denotes that atherosclerosis might start years before the diagnosis of gestational diabetes in vulnerable women.

Longer survival after the total repair of the Tetralogy of Fallot increases the importance of late complications such as right ventricular dysfunction. This is a prospective study of the right ventricular function in totally corrected Tetralogy of Fallot patients versus healthy children. Thirty-two healthy children were prospectively compared with 30 totally corrected Tetralogy of Fallot patients. Right ventricular myocardial tissue velocities, right ventricular myocardial performance index, and tricuspid annular plane systolic excursion were investigated as well as the presence and severity of pulmonary regurgitation. The two groups were age-and sex-matched. Mean systolic peak velocity (Sa) and tricuspid annular plane systolic excursion were significantly decreased, while myocardial performance index and early to late diastolic velocity (Ea/Aa) were significantly increased in the Tetralogy of Fallot patients. Early diastolic velocity (Ea) showed no significant difference between the two groups. Sa correlated significantly with tricuspid annular plane systolic excursion in both the normal children and totally corrected Tetralogy of Fallot patients. Myocardial performance index was significantly higher in the patients with moderate to severe pulmonary regurgitation than in those with mild regurgitation. However, there was no significant correlation between this index and right ventricular myocardial tissue velocities. In this study, systolic right ventricular function indices (Sa and tricuspid annular plane systolic excursion) were impaired in the totally corrected Tetralogy of Fallot patients. Myocardial performance index was affected by the severity of pulmonary regurgitation.

Isolated right bundle branch block (RBBB) is a common finding in the general population. The atrioventricular node (AVN) artery contributes to the blood supply of the right bundle branch. Our hypothesis was that the anatomy of the AVN artery and the pattern of dominancy differ between subjects with and without RBBB. We retrospectively studied the coronary angiography of 92 patients with RBBB and 184 age- and gender-matched controls without RBBB. All the subjects had angiographically proven normal coronary arteries. The dominant circulation and precise origin of the AVN artery were determined in each subject. Obtained data were compared between the two study groups. There was no significant difference between the two groups in terms of dominancy (p value = 0.200). Origination of the AVN artery from the right circulatory system was more common in both groups, but this pattern was more prevalent in the cases than in the controls (p value = 0.021). There was a great variation of the AVN artery origin. In the total study population, the AVN artery was more commonly separated from a non crux origin than from the crux area. The prevalence of the non-crux origination of the AVN artery was significantly higher in the cases than in the controls (p value < 0.001). While the origination of the AVN artery from the right circulatory system was more common in both groups, the prevalence of the right origin of the AVN artery was significantly higher in the cases than in the controls. We observed that the AVN artery most commonly originated from the dominant artery but not necessarily from the crux. The anatomy of the AVN artery but not the pattern of dominancy is somewhat different in subjects with RBBB compared with normal individuals.

Reports on the determinants of morbidity in coronary artery bypass graft surgery (CABG) have focused on outcome measures such as length of postoperative stay in the Intensive Care Unit (ICU). We proposed that major comorbidities in the ICU hampered the prognostic effect of other weaker but important preventable risk factors with effect on patients’ length of hospitalization. So we aimed at evaluating postoperative length of stay in the ICU and surgical ward separately. We studied isolated CABG candidates who were not dialysis dependent. Preoperative, operative, and postoperative variables as well as all classic risk factors of coronary artery disease were recorded. Using multivariate analysis, we determined the independent predictors of length of stay in the ICU and in the surgical ward. Independent predictors of extended length of stay in the surgical ward (> 3 days) were a history of peripheral vascular disease, total administered insulin during a 24-hour period after surgery, glycosylated hemoglobin (HbA1c), last fasting blood sugar of the patients before surgery, and inotropic usage after cardiopulmonary bypass. The area under the Receiver Operating Characteristic Curve (AUC) was found to be 0.71 and Hosmer-Lemeshow (HL) goodness of fit statistic p value was 0.88. Independent predictors of extended length of stay in the ICU (> 48 hours) were surgeon category, New York Heart Association functional class, intra-aortic balloon pump, postoperative arrhythmias, total administered insulin during a 24-hour period after surgery, and mean base excess of the first 6 postoperative hours (AUC = 0.70, HL p value = 0.94). This study revealed that the indices of glycemic control were the most important predictors of length of stay in the ward after cardiac surgery in all patients, diabetic or non-diabetic. However, because HbA1c level did not change under the influence of perioperative events, it could be deemed a valuable measure in predicting outcome in CABG candidates.

Diabetes mellitus is capable of impairing the myocardial function. Several studies have documented the influential impact of diabetes mellitus on the left ventricular function. The right ventricular function plays a significant role in the overall myocardial contractility; hence, this study was undertaken to evaluate the effect of diabetes mellitus type II on the right ventricular function. Twenty-two diabetic patients without any coronary artery disease, hypertension, or left ventricular dysfunction were studied. The right ventricular end diastolic diameter, tricuspid plane systolic excursion, right ventricular inflow Doppler parameters, longitudinal myocardial velocities, and deformation indices from the basal and apical segments of the right ventricular free wall of the case group were measured. The control group consisted of 22 healthy individuals. The tricuspid annular plane systolic excursion (TAPSE) and tricuspid peak early to peak late diastolic flow velocities ratio (E/A) in the diabetic patients were significantly lower than those of the control group patients (18.9 vs. 23.2, p value < 0.001 and 0.96 vs. 1.21, p value = 0.012), but there were no significant differences in the right ventricular end diastolic diameter and the right ventricular Tei index between the two groups (p value = 0.72). The right ventricular basal peak myocardial systolic velocity (SM) (12 cm/sec vs. 13.4 cm/sec; p value = 0.03), basal and apical right ventricular free wall systolic strain (-13.3% and -18.7% vs. -20.2% and -25.7%; p value = 0.001), and apical strain rate (-1.2 1/s vs. -1.6 1/s; p value = 0.008) were significantly lower in the study group. There was a weak correlation between the right ventricular function and HbA1c as well as the duration of diabetes mellitus and C-reactive protein. Our results suggest that diabetes mellitus type II can influence the right ventricular function in the absence of coronary artery disease, diastolic dysfunction, and pulmonary hypertension.

A secundum atrial septal defect is the most common congenital heart defect. Transcatheter treatment of secundum atrial septal defects is a popular and less invasive alternative to surgery. Procedural complications may occur in a wide spectrum, particularly device embolus as the most emergent one, but luckily they do not commonly occur in the clinical setting. Mortality from adverse events related to transcatheter treatment strategies is twentyfold higher than that of primary elective surgical closure. Here, we report an Amplatzer device embolus in a secundum atrial septal defect patient. The device was successfully removed with surgery, postoperative course was uneventful, and the patient was discharged from the hospital on the 5th postoperative day.

Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports of pain to florid shock. Traumatic tricuspid valve regurgitation is a rare cardiovascular complication of blunt chest trauma. Tricuspid valve regurgitation is usually begotten by disorders that cause the right ventricle to enlarge. Diagnosis is made by physical examination findings and is confirmed by echocardiography. We report two cases of severe tricuspid regurgitation secondary to the rupture of the chordae tendineae of the anterior leaflet following non-penetrating chest trauma. Both patients had uneventful postoperative courses.

One of the most serious complications of mitral valve replacement is left ventricular rupture and pseudoaneurysm formation, which is rare but potentially lethal. We herein present a late type of post mitral valve replacement and coronary artery bypass surgery pseudoaneurysm in a 74-year-old female, who was admitted to our hospital with a recent history of exertional dyspnea. She had the above-mentioned operation 10 months before. The diagnosis was made via two-dimensional and real-time three-dimensional transthoracic echocardiography. The prosthetic mitral valve was removed, and the large orifice of the pseudoaneurysm was closed by surgery. At one year's follow-up, the patient was in good condition.