The Journal of Tehran University Heart Center
Volume:8 Issue: 4, Oct 2013

There is a definite correlation between cardiovascular diseases and depressive disorders. Nevertheless, many aspects of this association have yet to be fully elucidated. Up to half of coronary artery disease patients are liable to suffer from some depressive symptoms, with approximately 20% receiving a diagnosis of major depressive disorders. Pharmacotherapy is a key factor in the management of major depression, not least in patients with chronic diseases who are likely to fail to show proper compliance and response to non-pharmacological interventions. Antidepressants are not deemed completely safe. Indeed, numerous side effects have been reported with the administration of antidepressants, among which cardiovascular adverse events are of paramount importance owing to their disabling and life-threatening nature. We aimed to re-examine some of the salient issues in antidepressant therapy vis-à-vis cardiovascular considerations, which should be taken into account when prescribing such medications.

There is controversy over the potential benefits/harms of the usage of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as regards the postoperative mortality of coronary artery bypass grafting (CABG). This study investigates the correlation between the in-hospital mortality of CABG and the preoperative administration of ACEI/ARB. Out of 10055 consecutive patients with isolated CABG from 2006 to 2009, 4664 (46.38%) patients received preoperative ACEI/ARB. Data were gathered from the Cardiac Surgery Registry of Tehran Heart Center. In-hospital mortality was defined as death within the same admission for surgery. Adjusted for confounders, multivariable logistic regression models were used to evaluate the impact of preoperative ACEI/ARB therapy on in-hospital death. The mean age of the patients was 60.04 ± 9.51 years and 7364 (73.23%) were male. Eighty-seven (0.86%) patients expired within 30 days. Multivariate analysis revealed that the administration of ACEI/ARB significantly protected against in-hospital deaths inasmuch as there were 33 (0.70%) vs. 54 (1.0%) deaths in the ACEI/ARB positive and negative groups, respectively (OR: 0.628; p value = 0.09). Patients without ACEI/ARB were more likely to have a higher global ejection fraction. Preoperative ACEI usage in patients undergoing CABG can be associated with decreased in-hospital mortality. Large-scale randomized clinical trials are suggested.

The ductus arteriosus connects the main pulmonary trunk to the descending aorta. The incidence of isolated patent ductus arteriosus (PDA) in full-term infants is about 1 in 2000. The Amplatzer Ductal Occluder (ADO) is recommended for PDAs with sizes larger than 2 mm. In this procedure, we must confirm the ADO position in PDA by aortogram from the arterial line. The purpose of this study was to determine the optimal release time of the ADO in the PDA closure procedure, especially in the absence of an arterial line for post-PDA aortography. This study recruited all patients scheduled to undergo PDA transcatheter closure with the ADO between September 2009 and September 2012 in our center. Age, weight, PDA diameter, systolic and diastolic pulmonic pressures, fluoroscopy time, and total angiographic time were studied. Major complications such as mortality and vascular complications were considered. We studied 237 patients in our investigation. We had 130 female and 107 male patients at a mean age of 34.3 ± 40.6 months and mean weight of 14.2 ± 7.8 kg. PDA sizes ranged from 2.1 to 6.2 mm and its mean was 3.7 ± 1.8 mm. Mean of fluoroscopy time was 11.4 ± 9.7 min and mean of total angiographic time was 42.0 ± 12.3 min. There were no significant complications. We herein describe a new sign, which proved extremely helpful during our PDA closure procedures with the ADO. By considering the angle between the ADO and the cable during the procedure, the operator can release the ADO safely.

Cardiopulmonary-cerebral resuscitation (CPCR) training is essential for all hospital workers, especially junior residents who might become the manager of the resuscitation team. In our center, the traditional CPCR knowledge training curriculum for junior residents up to 5 years ago was lecture-based and had some faults. This study aimed to evaluate the effect of a problem-based method on residents’ CPCR knowledge and skills as well as their evaluation of their CPCR trainers. This study, conducted at Tehran University of Medical Sciences, included 290 first-year residents in 2009-2010 - who were trained via a problem-based method (the problem-based group) - and 160 first-year residents in 2003-2004 - who were trained via a lecture-based method (the lecture-based group). Other educational techniques and facilities were similar. The participants self-evaluated their own CPCR knowledge and skills pre and post workshop and also assessed their trainers’ efficacy post workshop by completing special questionnaires. The problem-based group, trained via the problem-based method, had higher self-assessment scores of CPCR knowledge and skills post workshop: the difference as regards the mean scores between the problem-based and lecture-based groups was 32.36 ± 19.23 vs. 22.33 ± 20.35 for knowledge (p value = 0.003) and 10.13 ± 7.17 vs. 8.19 ± 8.45 for skills (p value = 0.043). The residents’ evaluation of their trainers was similar between the two study groups (p value = 0.193), with the mean scores being 15.90 ± 2.59 and 15.46 ± 2.90 in the problem-based and lecture-based groups – respectively. The problem-based method increased our residents’ self-evaluation score of their own CPCR knowledge and skills.

Transcatheter closure of patent ductus arteriosus (PDA) has become an alternative treatment to surgery. We evaluated the long-term results of the transcatheter closure of PDA with the Amplatzer Duct Occluder (ADO) in children. Between May 2004 and October 2012, 138 children with PDA (43 males and 95 females) underwent transcatheter PDA closure. Clinical, electrocardiographic, echocardiographic, and hemodynamic data were assessed pre and postprocedurally and at follow-up. The mean age of the patients at procedure was 3.53 ± 2.43 years (range = 1.1 to 9.5 years), mean weight was 11.9±4.6 kg (range = 6 to 29 kg), median pulmonary end diameter of the PDA was 5 mm (range = 4 to 15 mm), and median diameter of the ADO was 8 mm (range = 6 to 16 mm). The mean follow-up time was 43.4 ± 23.5 months (range = 13.5 to 98 months).The devices were successfully deployed in 136 (98.5%) patients. Device embolization occurred in 2 patients, immediately in one patient and during the first postprocedural night in the other patient. The first patient had percutaneous device retrieval, followed by implantation of a larger device. The second patient had surgical device removal and PDA ligation. Immediately after device implantation, trivial to mild residual shunts were detected in 112 (80%) patients; all the shunts, however, disappeared 24 hours after the procedure. One patient had left pulmonary artery stenosis with a gradient of 25 mm Hg at 24 hours'', 40 mmHg at one month''s, and 64 mmHg at 6 months'' follow-up. There were no cases of late embolization, aortic obstruction, late hemolysis, infective endocarditis, or death. Transcatheter PDA closure with the ADO was safe and effective, with a high success rate at long-term follow-up.

Despite several reports regarding the use of the Occlutech Figulla® Flex septal occluder (OFFSO(in adults, there are few reports on its use in children. We sought to study the result of the transcatheter closure of atrial septal defect (ASD) using the OFFSO in children ≤ 12 years. We enrolled 45 consecutive patients, ranging from 2.5 to 12 years of age, in two large pediatric cardiovascular centers. All the children underwent complete echocardiographic examination before the procedure. Defect/device ratio and device/weight ratio were measured. The device diameter to the cardiac diameter ratio (DD/CD ratio) in anteroposterior projection after device release and the DD/CD index were calculated by dividing the DD/CD ratio by the body surface area. Of the 45 enrolled patients, 25 (55%) were female. The range and mean ± standard deviation (SD) of age were 2.5 to 12 years and 6.8 ± 2.5 years, respectively. The range and mean ± SD weight were 8.5 to 37.0 kg and 19.7 ± 7.2 kg, respectively. Successful implantation was performed in all the patients. No major complications occurred in any of the subjects. We encountered one cobra head deformity in one patient. Neither residual shunt nor conduction abnormality was observed in any of the cases. Transcatheter ASD closure using the OFFSO was effective in our pediatric patients. Although this device needs relatively larger delivery sheaths, its use is safe while closing even large defects in children.

Myxomas are the most common benign cardiac tumors. Myxomas are more common in the left heart chamber than the right side chamber. An extracardiac origin presenting as a right atrial mass is very rare. We present a case of myxoma originating in the superior vena cava (SVC) in a 24-year-old man, who underwent surgical resection. Preoperative two-dimensional echocardiography demonstrated a mass in the right atrium. Intraoperatively, the tumor was found to have originated from the SVC orifice. The tumor was excised from the SVC by opening the one-third proximal portion of the SVC. Pathological examination revealed a myxoma, and one-year follow-up showed no evidence of the recurrence of any tumors in the SVC.

Hand ischemia is a rare complication of diabetes and some other chronic vascular diseases. Critical hand ischemia causes painful limbs and disability and requires urgent revascularization. There have been a few reports of successful trans-brachial percutaneous angioplasty in the upper extremity in the radial or ulnar artery. Herein, we report the results of the endovascular treatment of a 68-year-old diabetic patient with an ischemic hand ulcer due to the severe stenotic lesions of the infra-brachial arteries. The patient underwent successful angioplasty via the retrograde trans-femoral technique to avoid the drawbacks. At the first week of post-procedural follow-up, the patient’s finger was warm with a well–healing wound and reduced pain. In the next two months, he had no complaint of pain or active ulceration; the ulcer was well healed, and the hand was warm.The present case shows that history taking and physical examination should be followed by upper-extremity arteriography for the evaluation of hand ischemia. The trans-femoral approach enabled us to perform percutaneous catheterization for both diagnostic and interventional purposes. Not only is this strategy useful even for the severe stenotic disease of the distal parts of below-the-elbow arteries but also it avoids the unpleasant complications of antegrade brachial cannulation.

True saccular aneurysm is exceptional in coarctation of aorta in children. A 6-year-old girl with headache and systemic arterial hypertension referred to our center for cardiovascular evaluation. Physical examination revealed high blood pressure and weak lower extremity pulses. Two-dimensional and Doppler echocardiography and angiography demonstrated a saccular aneurysm of the descending aorta, 5×4 cm in size, associated with aortic coarctation. Aneurysmectomy was performed without cardiopulmonary bypass. The section of the aorta containing the coarctation and the aneurysm was resected and replaced with a 15-mm woven polyester graft. Histological examination revealed a thin walled aneurysm with hyalinosis changes and decreased elastic fibers. One-year echocardiographic follow-up revealed no gradient across of Dacron tube and hypertension decreased to normal level.