The Journal of Tehran University Heart Center
Volume:8 Issue: 1, Jan 2013

Echocardiography is a non-invasive diagnostic technique which provides information regarding cardiac function and hemodynamics. It is the most frequently used cardiovascular diagnostic test after electrocardiography and chest X-ray. However, in a patient with acute chest pain, Transthoracic Echocardiography is essential both for diagnosing acute coronary syndrome, zeroing on the evaluation of ventricular function and the presence of regional wall motion abnormalities, and for ruling out other etiologies of acute chest pain or dyspnea, including aortic dissection and pericardial effusion. Echocardiography is a versatile imaging modality for the management of patients with chest pain and assessment of left ventricular systolic function, diastolic function, and even myocardial and coronary perfusion and is, therefore, useful in the diagnosis and triage of patients with acute chest pain or dyspnea.This review has focused on the current applications of echocardiography in patients with coronary artery disease and myocardial infarction.

Despite major advances in percutaneous coronary intervention (PCI), in-stent restenosis (ISR) remains a therapeutic challenge. We sought to compare the mid-term clinical outcomes after treatment with repeat drug-eluting stent (DES) implantation (“DES sandwich” technique) with DES placement in the bare-metal stent (DES-in-BMS) in a "real world" setting. We retrospectively identified and analyzed clinical and angiographic data on 194 patients previously treated with the DES who underwent repeat PCI for ISR with a DES or a BMS. ISR was defined, by visual assessment, as a luminal stenosis greater than 50% within the stent or within 5 mm of its edges. We recorded the occurrence of major adverse cardiac events (MACE), defined as cardiac death, non-fatal myocardial infarction, and the need for target vessel revascularization (TVR). Of the 194 study participants, 130 were men (67.0%) and the mean ± SD of age was 57.0 ± 10.4 years, ranging from 37 to 80 years. In-hospital events (death and Q-wave myocardial infarction) occurred at a similar frequency in both groups. Outcomes at twelve months were also similar between the groups with cumulative clinical MACE at one-year follow-up of 9.6% and 11.3% in the DES-in-BMS and the DES-in-DES groups, respectively (p value = 0.702). Although not significant, there was a trend toward a higher TVR rate in the intra-DES ISR group as compared to the intra-BMS ISR group (0.9% BMS vs. 5.2% DES; p value = 0.16). Our study suggests that the outcome of the patients presenting with ISR did not seem to be different between the two groups of DES-in-DES and DES-in-BMS at one-year follow-up, except for a trend toward more frequent TVR in the DES-in-DES group. Repeat DES implantation for DES restenosis could be feasible and safe with a relatively low incidence of MACE at mid-term follow-up.

Acute kidney injury (AKI) is a common and life-threatening complication following coronary artery bypass graft (CABG). Neutrophil gelatinase-associated lipocalin (NGAL) and Cystatin C have shown to be good predictive factors for AKI. Recently, there has been a growing interest in the use of hypertonic saline in cardiac operations.The purpose of this study was to evaluate the prophylactic anti-inflammatory effect of hypertonic saline (Group A) infusion versus normal saline (Group B) on serum NGAL and Cystatin C levels as the two biomarkers of AKI in CABG patients. This randomized double-blinded clinical trial recruited 40 patients undergoing CABG in Tehran Heart Center, Tehran, Iran. After applying exclusion criteria, the effects of preoperative hypertonic saline (294 meq Na) versus normal saline (154 meq Na) infusion on serum NGAL and Cystatin C levels were investigated in three intervals: before surgery and 24 and 48 hours postoperatively. The probable intraoperative or postoperative confounders, including pump time, cross-clamp time, heart rate, systolic and diastolic blood pressures, central venous pressure, arterial pH, partial pressure of arterial oxygen, fraction of inspired oxygen, blood sugar, Na, K, Mg, hemoglobins, white blood cells, hematocrits, and platelets, were recorded and compared between the two groups of study. The study population comprised 40 patients, including 25 (62.5%) males, at a, mean age ± SD of 61.75 ± 8.13 years. There were no statistically significant differences between the patient's basic, intraoperative, and postoperative characteristics, including intraoperative and postoperative hemodynamic variables and supports such as inotropic use. Intra-aortic balloon pump use and mortality were not seen in our cases.Three patients in the normal saline group and one patient in the hypertonic saline group had serum NGAL levels greater than 400 ng/ml. Moreover, 10 patients in Group A and 17 patients in group B showed a rise in serum Cystatin C levels above 1.16 mg/dl.Patients with AKI had significantly elevated NGAL and Cystatin C levels (p value < 0.001), but there were no significant differences in the decrease in the NGAL level in the hypertonic saline group versus the normal saline group (230.91 ± 92.68 vs. 239.74 ± 116.58 ng/ml, respectively; p value = 0.792), or in the decrease in the Cystatin C level in the hypertonic saline group versus the normal saline group (1.05 ± 0.26 vs. 1.06 ± 0.31, respectively; p value = 0.874). Pre-treatment of CABG patients with hypertonic saline had no significant effect on serum NGAL and Cystatin C levels compared to the normal saline-receiving group. Our present data, albeit promising, have yet to fully document outcome differences.

Significant elevation of cardiac biomarkers after percutaneous coronary intervention (PCI) is associated with increased mortality. However, clinical importance of lesser degrees of cardiac enzyme elevation has not been well understood. Multiple factors might have an etiologic role, and the incidence of myonecrosis has not changed dramatically despite pharmacological and technological advances in PCI. The aim of this study was to evaluate the role of intracoronary (IC) Adenosine in preventing the elevation of cardiac enzymes as a marker of myonecrosis after PCI in patients with chronic stable angina. Two hundred sixty patients with chronic stable angina who were candidates for PCI were randomly assigned to double-blinded pretreatment with IC Adenosine or placebo before crossing of the guide wire. The patients were observed during the hospital course, and blood samples were obtained in standard intervals after the intervention for cardiac biomarkers. The primary end point of this study was post-PCI myonecrosis, and secondary end point was safety of IC Adenosine administration in the setting of PCI in patients with chronic stable angina. Of the 260 patients, who were initially randomized, finally 83 patients were analyzed in the placebo and 96 in the Adenosine arms. The study patients were comparable in clinical and angiographic characteristics. The mean of the patients’ age was 57.3 years (range = 35 to 79 years), and 71.5% were male. There were no differences in the mean serum cardiac biomarkers between the study groups (mean creatine kinase-MB [CK.MB] level of 29.5 ± 14.5 IU/L in the placebo group and 31.5 ± 18.5 IU/L in the control group; p value = 0.41; mean cardiac troponin I (cTnI) level of 0.097 ± 0.178 µg/L in the placebo group and 0.167 ± 0.5 µg/L in the control group; p value = 0.24). Despite promising results in primary PCI, our study showed that a strategy of IC Adenosine pretreatment is not beneficial in reducing post-PCI myonecrosis in patients with chronic stable angina and should not be routinely used.

Heart disease is the main cause of mortality and morbidity in patients with beta thalassemia, rendering its early diagnosis vital. We studied and compared echocardiographic findings in patients with beta thalassemia major, patients with beta thalassemia intermedia, and a control group. Eighty asymptomatic patients with thalassemia major and 22 asymptomatic cases with thalassemia intermedia (8-25 years old) were selected from those referred to Ali Asghar Hospital (Zahedan-Iran) between June 2008 and June 2009. Additionally, 80 healthy individuals within the same age and sex groups were used as controls. All the individuals underwent echocardiography, the data of which were analyzed with the Student t-test. The mean value of the pre-ejection period/ejection time ratio of the left ventricle during systole, the diameter of the posterior wall of the left ventricle during diastole, the left and right isovolumic relaxation times, and the right myocardial performance index in the patients with beta thalassemia major and intermedia increased significantly compared to those of the controls, but the other parameters were similar between the two patient groups. The mean values of the left and right pre-ejection periods, left ventricular end systolic dimension, and left isovolumic contraction time in the patients with thalassemia intermedia increased significantly compared to those of the controls. In the left side, myocardial performance index, left ventricular mass index, isovolumic contraction time, and deceleration time exhibited significant changes between the patients with thalassemia major and those with thalassemia intermedia, whereas all the echocardiographic parameters of the right side were similar between these two groups. The results showed that the systolic and diastolic functions of the right and left sides of the heart would be impaired in patients with thalassemia major and thalassemia intermedia. Consequently, serial echocardiography is suggested in asymptomatic patients with beta thalassemia for an early diagnosis of heart dysfunction and proper treatment.

Reintubation in patients after cardiac surgery is associated with undesirable consequences. The purpose of the present study was to identify variables that could predict reintubation necessity in this group of patients. We performed a prospective study in 1000 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass. The patients who required reintubation after extubation were compared with patients not requiring reintubation regarding demographic and preoperative clinical variables, including postoperative complications and in-hospital mortality. Postoperatively, 26 (2.6%) of the 1000 patients studied required reintubation due to respiratory, cardiac, or neurological reasons. Advanced age and mainly cardiac variables were determined as univariate intra- and postoperative predictors of reintubation (all p values < 0.05). Multiple logistic regression analysis revealed lower preoperative (p = 0.014; OR = 3.00, 95%CI: 1.25 - 7.21), and postoperative ejection fraction (p = 0.001; OR = 11.10, 95%CI: 3.88 - 31.79), valvular disease (p = 0.043; OR = 1.84, 95%CI: 1.05 - 3.96), arrhythmia (p = 0.006; OR = 3.84, 95%CI: 1.47 - 10.03), and postoperative intra-aortic balloon pump requirement (p = 0.019; OR = 4.20, 95%CI: 1.26 - 14.00) as the independent predictors of reintubation. These findings reveal that cardiac variables are more common and significant predictors of reintubation after cardiac surgery in adult patients than are respiratory variables. The incidence of this complication, reintubation, is low, although it could result in significant postoperative morbidity and mortality.

Pleurotomy during coronary artery bypass grafting (CABG) may cause post-operative events, mostly pulmonary complications. In this study, we evaluated the influence of pleurotomy during CABG on the clinical outcome following left internal mammary artery (LIMA) harvesting. Between March and August 2009, 102 patients who underwent cardiac surgery were enrolled in this study and divided into two groups: group A (n = 48, 36 male and 12 female patients at a mean age of 56.5 ± 11.2 years) underwent routine CABG and pleurotomy and group B (n = 54, 46 male and 8 female patients at a mean age of 55.4 ± 10.3 years) had CABG with intact pleura. The patients were compared regarding their demographic data, surgical data, and postoperative events. The incidence of postoperative pericardial effusion was similar between the groups, but the incidence of postoperative pulmonary complications such as pleural effusion (except for mild pleural effusion) on the second (no: 10.4%, mild: 41.7%, moderate: 45.8% and severe: 2.1% in group A versus no: 42.6%, mild: 44.4%, moderate: 13%, and severe: 0 in group B) and fifth postoperative days (no: 27.1%, mild: 33.3%, moderate: 35.4%, and severe: 4.2% in group A versus no: 42.6%, mild: 44.4%, moderate: 13%, and severe: 0 in group B) was significantly lower in group B (p value < 0.001 and p value = 0.007, respectively). Also, the incidence of atelectasis (except for mild atelectasis) on the second (no: 2.1%, mild: 22.9%, moderate: 72.9%, and severe: 2.1% in group A versus no: 9.2%, mild: 59.3%, moderate: 31.5%, and severe: 0 in group B) and fifth postoperative days (no: 22.9%, mild: 39.6%, moderate: 35.4%, and severe: 2.1% in group A versus no: 39.6%, mild: 49.1%, moderate: 11.3%, and severe: 0 in group B) was significantly higher in group A (p value < 0.001 and p value = 0.004, respectively). Postoperative partial oxygen pressure and O2 saturation were similar between the groups, but partial carbon dioxide pressure was significantly lower in group A (p value = 0.017). Amount of bleeding (p value = 0.008) and duration of hospitalization (p value = 0.002) were significantly higher in group A than those in group B. Our results indicate that keeping the pleura intact has beneficial effects on the respiratory function, without increasing the incidence of postoperative pericardial effusion.

Although coronary artery disease (CAD) is not common among individuals younger than 40-45 years of age, a small percentage of this age group needs to undergo surgical revascularization because of CAD. Why some people are at higher risk of developing premature CAD is not clearly known. Increased number of traditional risk factors or genetic predisposition may play significant roles in this regard.A 22-year-old man with a negative history for all traditional risk factors except for a family history of premature CAD referred to our center due to an episode of myocardial infarction of one month’s duration. He had no congenital heart disease and no hypercoagulable state, and there was a negative history of drug abuse.His coronary angiography showed extensive CAD. He underwent coronary artery bypass grafting and he left the hospital in good healthy condition. One year after surgery, his follow-up showed that he was symptom free and he still had no new traditional risk factor. It seems that a positive family history of premature CAD is an important and independent risk factor for developing premature CAD and individuals with this type of history should be treated more cautiously.

Complexity of some congenital heart diseases sometimes necessitates a combination of interventional procedures and surgery, amongst which intraoperative stent implantation is one of the most common. We herein report a successful hybrid procedure in a cyanotic adult patient who had undergone no procedure in childhood. The patient was a 24-year-old cyanotic male (oxygen saturation in the room air was 65%) who presented with dyspnea. According to echocardiography, catheterization, and cardiac magnetic resonance imaging data, the patient was amenable to the Fontan surgery. However, because of significant left pulmonary stenosis and his age, he first underwent a hybrid procedure (Glenn shunt and left pulmonary artery [LPA] stenting). After the procedure, oxygen saturation rose to 83%. At six months’ follow-up of the patient, exercise capacity and cyanosis had improved significantly, with O2 saturation having reached near 85% by pulse oximetry.

As the major hazard of percutaneous vertebroplasty (PV), cement extravasation into the venous system, systemic embolism, and spinal canal has been previously reported. However, to our knowledge, only one case of the arterial migration of cement has been previously reported that is directly associated with this technique without any symptom in the immediate post-intervention and in the follow-up period. An arterial embolus of cement occurred in a 46-year-old woman undergoing lumbar PV for breast cancer metastasis. Less than one hour later, the patient complained of severe pain and numbness in her left leg. A diagnosis of acute left leg ischemia due to the acute occlusion of the infrapopliteal arteries by the cement was made. Transluminal angioplasty (PTA) for the infrapopliteal arteries was recommended because there were diffuse and long vessel involvements, leaving no distal targets for bypass vascular surgery. The patient's postoperative course was uncomplicated; the extremity tenderness and mottled skin were improved. A follow-up ultrasound 2 months later revealed an acceptable distal flow in the arteries of the affected limb, and the patient remained asymptomatic (except for a mild leg pain on exertion) at the one-year follow-up examination. In conclusion, PTA may save the limb from amputation in case of peripheral arterial embolism caused by cement during PV.