Journal of Cardiovascular and Thoracic Research
Volume:6 Issue: 2, Jun 2014

The relationship and interactions between stress hormones and post-traumatic stress disorder (PTSD) are well established from both animal and human research studies. This interaction is especially important in the post-operative phase of cardiac surgery where the development of PTSD symptoms will result in increased morbidity and mortality and prolong length of stay for critically ill cardiac surgery patients. Cardiopulmonary bypass itself will independently result in massive inflammation response and release of stress hormones in the perioperative period. Glucocorticoid may reduce this response and result in reduction of PTSD symptom clusters and therefore improve health outcome. In this review, we plan to conduct a systemic review and analysis of the literatures on this topic.

The QRS represents the simultaneous activation of the right and left ventricles, although mostof the QRS waveform is derived from the larger left ventricular musculature. Although normalQRS duration is <100 millisecond (ms), its duration and shape are quite variable from patient topatient in idiopathic dilated cardiomyopathy (IDCM). Prolongation of QRS occurs in 14% to 47%of heart failure (HF) patients. Left bundle branch block (LBBB) is far more common than rightbundle branch block (RBBB). Dyssynchronous left ventricular activation due to LBBB and otherintraventricular conduction blocks provides the rationale for the use of cardiac resynchronizationtherapy with biventricular pacing in patients with IDCM. Fragmented QRS (fQRS) is a markerof depolarization abnormality and present in significant number of the patients with IDCM andnarrow QRS complexes. It is associated with arrhythmic events and intraventricular dyssynchrony.The purpose of this manuscript is to present an overview on some clinical, echocardiographic andprognostic implications of various QRS morphologies in patients with IDCM.

Excessive bleeding presents a risk for the patient in cardiovascular surgery. Local haemostatic agents are of great value to reduce bleeding and related complications. TachoSil (Nycomed, Linz, Austria) is a sterile, haemostatic agent that consists of an equine collagen patchcoated with human fibrinogen and thrombin. This study evaluated the safety and efficacy of TachoSil compared to conventional technique. Forty-two patients scheduled for open heart surgeries, were entered to this study from August 2010 to May 2011. After primary haemostatic measures, patients divided in two groups based on surgeon’s judgment. Group A: 20 patients for whom TachoSil was applied and group B: 22 patients that conventional method using Surgicel (13 patients) or wait and see method (9 cases), were performed in order to control the bleeding. In group A, 10 patients were male with mean age of 56.95±15.67 years and in group B, 9 cases were male with mean age of 49.95±14.41 years. In case group 70% (14/20) of the surgeries were redo surgeries versus 100% (22/22) in control group. Baseline characteristics were similar in both groups. In TachoSil group 75% of patients required transfusion versus 90.90% in group B (P=0.03).Most transfusions consisted of packed red blood cell; 2±1.13 units in group A versus 3.11±1.44 in group B (P=0.01), however there were no significant differences between two groups regarding the mean total volume of intra and post-operative bleeding. Re-exploration was required in 10% in group A versus 13.63% in group B (P=0.67). TachoSil may act as a superior alternative in different types of cardiac surgery in order to control the bleeding and therefore reducing transfusion requirement.

Percutaneous coronary intervention (PCI) may be associated with Thrombotic complications. Unfractionated heparin (UFH) is a potent and preferable antithrombotic agent during this procedure. Activated clotting time (ACT) is a good assay for accurate titration of UFH during PCI. The aim of this study was to evaluate ACT levels 10 minutes after administration of 100U/kg IV heparin and determining its associated factors. This study was performed in Madani hospital, Tabriz, Iran between January 2013 to January 2014. One hundred and two patients candidates for elective PCI were enrolled in the study. Data including demographic and risk factors were collected. The range of ACT was between 165 to 750 seconds (mean 319.8 seconds), 52 (51%) patients had ACT levels lower than 300sec and 12 (11.8%) patients had ACT levels between 300 to 350 seconds which is known optimal range and 38 (37.2%) cases had ACT levels above this value. Major risk factors had no effect on ACT value, but there was a trend to higher levels with increasing age (P=0.06). There was no difference in the rate of major or minor bleeding with respect to ACT levels (P=0.52). There was a trend to higher rate of minimal bleeding in those with ACT >350 sec (P=0.06). Weight based UFH injection may result in suboptimal anticoagulation during the procedure. Routine ACT measurement may be necessary to ascertain adequate anticoagulation. Major risk factors had no effect on ACT level and it was not associated with the rate of bleeding.

Prognostic differences between anterior and inferior wall Myocardial Infarction (MI) has been extensively investigated, but there is limited information about similar comparison between inferior wall MI caused by right coronary artery (RCA) and left circumflex artery (LCX) occlusion. The aim of present study was to compare prognostic differences between LCX- and RCA-related acute inferior wall ST-segment elevation MI (STEMI) treated by routine adjunctive angioplasty after receiving thrombolytic therapy (TLT). Between March 2012 and June 2013 one hundred fifty consecutive patients with acute inferior wall STEMI were studied. Patients were divided into two groups according to the infarct related artery (LCX vs. RCA). All patients underwent routine adjunctive angioplasty after TLT during the index hospitalization and clinical characteristics and outcomes were compared. RCA and LCX arteries were occluded in 97 (64.7%) and 53 (35.3%) of patients, respectively. Two groups were similar in baseline characteristics except multiple-vessel disease was more prevalent with LCX occlusion (p= 0.008). There was a higher cardiac enzyme release (p< 0.001), more significant mitral regurgitation (MR) (p= 0.015), and lower left ventricular ejection fraction (LVEF) (p= 0.01) in patients with LCX occlusion. Multivariate analysis showed cTn-I release, occurrence of MR, and lower LVEF as independent factors leading to poor outcome. There were higher cTn-I release, MR occurrence, and lower LVEF in LCX-related acute inferior wall STEMI, all associated with poor outcome. Therefore, patients with ECG finding in favour of LCX occlusion should be considered as high risk and an invasive approach should be planned.

Several observational studies comparing outcomes between female and malepatients after coronary artery bypass grafting (CABG) have shown that operative mortalityrate is higher among female patients than in male patients. However, some conflicting studiesreport that early mortality among female patients is equivalent to that among male patients. Weinvestigated predictive factors of morbidity, mortality and survival in female patients undergoingisolated conventional CABG. Between January 2002 and December 2009, 1657 patients underwent isolatedconventional CABG in our clinic. 21.8% (n=361) of patients were female and 78.2%(n=1296) males. Advanced age (P<0.0001), hypertension (P<0.0001), diabetes (P<0.0001), andhyperlipidemia (P<0.0001) were the independent predictive factors among female patients. Meanin-hospital mortality rates were 5.8% and 3.2%; for females and males, respectively (P=0.029).Prolonged ventilatory support (P=0.009) and postoperative atrial fibrillation (P=0.049) were theindependent predictive factors of in-hospital mortality in female patients. Cardiopulmonarybypass time (P=0.041), prolonged ventilatory support (P<0.0001), and postoperative atrialfibrillation (P=0.031) were the independent predictive factors of in-hospital mortality in malepatients. Mean follow-up was 47.51±25.06 months and 48.42±25.21 months among female andmale patients (P=0.820). In follow-up, mortality rate was 6.1% (n=22) among female patients and4.6% (n=60) among male patients (P=0.272). Left internal thoracic artery (LITA) usage (P=0.001)was the independent predictive factor of survival in female patients. In-hospital mortality rate was higher in female patients. Length of ICU and hospitalstay, and mid-term survival was similar between female and male patients.

The plasma N-terminal probrain natriuretic peptide (NT-proBNP) level is animportant diagnostic and prognostic marker of heart failure. Recent studies have suggestedurinary NT-proBNP as a new and simple test for diagnosis of heart failure. We aim to comparediagnostic value of plasma, fresh and frozen urine levels of N-terminal probrain natriureticpeptide (NT-proBNP) for detecting heart failure. Between January 2010 and January 2012, we measured urine and plasma levels of NTproBNPin 98 patients with chronic heart failure (CHF) and 29 age- and sex-matched healthycontrol subjects. There were significant correlations between plasma NT-proBNP and fresh (r=0.45,p<0.001) and frozen (r=0.42, p<0.001) urine NT-proBNP concentrations in CHF patients. Due toreceiver operating curve analysis, fresh and frozen urine NT-proBNP could diagnose HF with areaunder curve (AUC) of 0.73±0.04 (p<0.001) and 0.65±0.05 (p=0.01) with sensitivity and specificityof 73.97%, 58.62%, and 65.31%, 62.07%, for a cut-off of 94.2 and 96 pg/mL, respectively. PlasmaNT-proBNP had greater AUC (0.94±0.02, p<0.001) and better sensitivity and specificity (94.9%,89.66% for cut-off of 414.5 pg/mL). There was no significant correlation between LVEF andplasma, fresh and frozen urine NT-proBNP levels in CHF patients. Plasma NT-proBNP is still the best diagnostic marker with high sensitivity andspecificity; however, urinary especially fresh urine NT-proBNP may be a surrogate to plasma NTproBNPfor diagnosing HF with acceptable accuracy.

Coarctation of aorta is the fourth most common cardiac lesion requiringintervention. While surgery used to be the only treatment option, endovascular intervention isnow considered the first option in simple coarctation lesions. Despite increased popularity, thereare currently no FDA approved stents for use in coarctation of aorta and data on the outcome ofthis procedure is still sparse. Between October 2004 and June 2010, 33 patients who underwent treatment withCheatham-Platinum stents for coarctation of aorta were retrospectively studied. All the patientsunderwent control CT scans at 6 month and echocardiography at 1 year follow-up. There were 17 females and 16 males with a mean age of 26.64 ± 16.30 years (range 2-71years). The mean stent length and balloon diameter were 3.18 ± 0.56 mm and 15.7 ± 3.12 mmrespectively. We achieved an immediate success rate of 96.9% with the only complication of aorticrupture which led to our single mortality in this series. At 6 month follow up no complicationswere noted in the CT scans. The mean echocardiographic aortic arch gradient at one year followup was 21.73 ± 11.06 mmHg. This study is one of the few cohorts of patients with stenting for coarctation ofaorta in Iranian population which comprised a diverse group of patients from early childhoodto elderly. It was demonstrated in this study that stenting for coarctation of aorta is a safe andeffective procedure if done carefully and performed in selected patients.

Patients with low serum albumin and abnormal BMI may be at the risk of death and other complications after surgery. This could be remarkable in patients with coronary arteries bypass graft surgery. Therefore, we decided to evaluate the impact of these factors associated with survival and outcome after cardiac surgery. A cross-sectional study was performed from 2009 until 2012 on 345 patients who underwent coronary artery bypass grafts. Also Patients were monitored for a year. Patients’ information was collected and then the patients were analyzed for body mass index (BMI) and serum albumin and their effects on postoperative outcomes. P value <0.05 was considered statistically significant. Mortality after CABG operation was not of a significant relation in patients with low BMI (BMI <20), normal and high (BMI> 30). Obese patients are more susceptible to myocardial infarction in postoperative period (P=0.02). Pneumonia after surgery in these patients was more common than others (P= 0.023); however, low serum albumin was significantly associated with mortality following operation (P<0.001). Reoperation due to bleeding (P<0.001) and required mechanical ventilation for more than a day (P=0.019) were significantly associated with low serum albumin. In conclusion, the high or low BMI alone did not increase mortality after cardiac surgery. However, postoperative morbidity in obese patients may be greater than others. Low serum albumin may increase the risk of mortality and postoperative complications as well. Therefore, it seems ameliorating serum albumin can be effective more than body mass index in improving the outcome of patients after CABG surgery.

Single coronary arteries are rare congenital anomalies in which the whole heart circulationis supplied by a coronary artery arising from a single ostium. Single left coronary artery withright coronary artery (RCA) originating from distal left circumflex artery (LCX) is a very rareanomaly with only few cases reported in the literature. We report a 44 years old male presentingwith anterior myocardial infarction who was found to have a single left coronary artery duringangiography. RCA had an abnormal origin arising from distal of a dominant LCX that retrogradelyfollowed the course of a normal RCA to the base of the heart. A brief review of the reported caseswith emphasis on the clinical significance of this unusual anomaly is presented.