Iranian Heart Journal
Volume:21 Issue: 2, Summer 2020

Albeit coronary artery angiography is the gold standard of the diagnosis of coronary artery disease (CAD), coronary artery calcification (CAC) is a less invasive diagnostic method. We evaluated pulsed-wave velocity (PWV) as another accessible diagnostic tool to detect early CAD in the Iranian population.

From March 2016 to March 2017, we enrolled 350 patients referred for an evaluation of CAD to Rajaie Cardiovascular, Medical, and Research Center (Tehran, Iran). The patients underwent coronary artery computed tomography angiography, and their CAC scores were measured simultaneously. The PWV index was defined as the distance between the brachial and dorsalis pedis arteries divided by time, and the correlations between the PWV index and the CAC score and known CAD risk factors were assessed.

From 350 patients, 52.3% were men and the rest were women. The mean PWV was 8.7 ± 2.2 m/s and the mean CAC score was 251 ± 99.52. There was no significant relationship between the CAC score and the PWV index (P = 0.16). In the women, the CAC score and the PWV index were meaningfully higher (P ≤ 0.001 and P < 0.04, respectively). The CAC score was significantly different between the patients with and without CAD (P <0.001), whereas there was no difference concerning the PWV index (P = 0.31). Among all CAD risk factors, hypertension and diabetes mellitus were significantly correlated with the CAC score (P = 0.001 and P = 0.015, correspondingly) and the PWV index (P = 0.001 and P = 0.009, respectively).

In contrast to some recent studies that have shown a significant increase in the PWV index in relation to the CAC score, our results did not prove it. The PWV index, thus, needs further studies if it is to be fully utilized in clinical practice

Nowadays, the attention is more set on the complications of the Fontan surgery such as protein-losing enteropathy (PLE). Determining the frequency rate and the contributing factors of the Fontan surgery complications like PLE would confer optimized preventive approaches, reduced rates of adverse effects, and improved prognosis and survival. 17 This cross-sectional study aimed to determine the prevalence and associated factors of PLE in a referral heart center.

The present cross-sectional analysis was performed on 73 patients using history taking, careful clinical examinations, laboratory tests (eg, fecal alpha-1-antitrypsin, complete cell blood count, chemistry, and venous blood gas), and echocardiographic and angiographic evaluations.

In our study, the prevalence of PLE was 4 (5.47%) cases. The associated factors were edema, diarrhea, abdominal pain, ascites, and hypoalbuminemia. The echocardiographic and angiographic findings revealed that the left ventricular ejection fraction was significantly reduced in our patients with PLE.

In light of our results, we conclude that in any post-Fontan surgery patient exhibiting clinical manifestations such as edema, diarrhea, abdominal pain, or ascites, screening for fecal alpha-1-antitrypsin can be helpful for the early detection of PLE.

Rheumatic heart disease is the main cause of mitral stenosis in developing countries. The assessments of left atrial deformation have yielded promising results in the evaluation of atrial function and the prediction of the long-term outcomes of many cardiac diseases. In this study, we sought to assess peak left atrial longitudinal strain (PALS) measures in patients with severe rheumatic mitral stenosis and to evaluate its variations regarding different valve areas.

Patients with severe symptomatic rheumatic mitral stenosis were recruited for the study. Mitral valve planimetry was performed via 3D evaluations using the multiplanar reconstruction method. PALS was measured by speckle-tracking echocardiography.

Eighty-four patients were enrolled in the study. The mean PALS was 11.18 ± 6.40% among the patients. The PALS measures were significantly higher in the patients in the sinus rhythm than in the group with atrial fibrillation (12.32 ± 6.38% vs 9.04± 5.74%; P = 0.03). The left atrial strain measures had a significant correlation with the mitral valve area and a significant reverse correlation with the left atrial volume index (r = 0.3, P = 0.08 and r = 0.28, P = 0.02, respectively). No significant difference was demonstrated in the PALS measures between the patients with the Wilkin score of 8 or less (32%, 25 patients) and those with the Wilkin score of 9 or more (67%, 55 patients).

Peak systolic left atrial strain was severely reduced in our patients with severe mitral stenosis. The severity of longitudinal strain impairment correlated with the valve area; however, it did not have a significant relationship with the Wilkin score of the valve. (Iranian Heart Journal 2020; 21(2): 21-26)

Preoperative use of angiotensin-converting enzyme inhibitors (ACEIs) is an independent predictor of the need for inotropic support postoperatively and hypotension during surgery; consequently, some surgeons suggest that ACEIs be discontinued prior to coronary artery bypass graft surgery (CABG). However, the optimal time of ACEI discontinuation before CABG remains controversial. In this study, we compared the effects of ACEI discontinuation 12 and 24 hours before open-heart surgery on the hemodynamic status of patients during surgery.

This randomized controlled trial was conducted on patients undergoing elective CABG. The patients were randomly divided into 2 groups: in the first group, ACEIs were discontinued 12 hours before CABG and in the second group, ACEIs were discontinued 24 hours before CABG. Hemodynamic evaluations including blood pressure (systolic, diastolic, and mean arterial pressures), the heart rate, and the hemoglobin level were performed.

The trends of changes in systolic blood pressure (P = 0.41), diastolic blood pressure (P = 0.360), the heart rate (P = 0.11), and the hemoglobin level (P = 0.92) were not significantly different between the 2 groups over time. The mean arterial pressure was significantly different between the groups over time (P = 0.038). Likewise, the mean arterial pressure in the 24-hour group was significantly higher than that of the other group until the time of sternotomy, after which time the mean arterial pressure in the 12-hour group was significantly higher.

ACEI discontinuation before CABG had some effects on the hemodynamics of our patients during anesthetic induction, including the prevention of hypotension during surgery; nonetheless, our data did not show the optimal time to stop ACEIs prior to CABG. (Iranian Heart Journal 2020; 21(2): 27-33)

The aim of this study was to determine the relationship between nurses’ work shifts in the intensive care unit (ICU) and the time of endotracheal extubation after cardiac surgery.

The present study enrolled 210 patients that underwent cardiac surgery in a university referral cardiovascular center in 2018. Samples were ed via the convenience sampling method adult patients that underwent elective cardiac surgery. The study samples were divided into 3 groups based on their admission time in the ICU: before 2 pm (morning shift), between 2 and 7 pm (evening shift), and after 7 pm (night shift). The patients’ demographic characteristics, risk factors, and intraoperative and postoperative clinical variables were collected. Information regarding the time of admission into the ICU, the time of readiness for extubation, and the actual time of extubation was recorded. Finally, these times were compared between the patients admitted into ICU in the 3 abovementioned work shifts.

The study population was comprised of 210 patients, 142 (67.6%) male and 68 (32.4%) female, at an average age of 55 years old (44–63). According to the findings, tracheal extubation was usually performed in the work shift after the patients’ admission time. There was a significant difference between the time of readiness for extubation and the actual time of tracheal tube removal on the different shifts, with the time being about 1 hour longer on the night shift than on the evening or morning shift (P < 0.05).

Our cardiac surgery patients who were admitted into the ICU on the morning and evening shifts were ready for extubation earlier than those admitted on the night shift. (Iranian Heart Journal 2020; 21(2): 34-40)

Most patients with mitral valve prolapse (MVP) are asymptomatic with a normal life expectancy; however, between 5% and 10% of them have progression to severe mitral regurgitation (MR). Because of this silent progression, the size and ejection fraction of the left ventricle are very important in decision-making for surgery in asymptomatic patients with MR. A 3D assessment of LV volumes and ejection fraction is preferred to 2D echocardiography because of its accuracy and reproducibility.

Between April 3, 2018, and February 20, 2019, the present study enrolled 50 patients suffering MVP with relatively severe MR undergoing transesophageal echocardiography at Rajaie Cardiovascular, Medical, and Research Center, affiliated with Iran University of Medical Sciences. The ejection fraction was analyzed via the visual 2D method, in addition to 3 other

the Simpson biplane, 3D full volume, and 3D heart model.

Of the 4 measurement methods, the 3D heart model had the highest agreement with the Simpson biplane method (ICC: 0.859, 95% CI: 0.745 to 0.922). The agreement rate between the 3D heart model and the 3D full volume was 72% and between the 3D heart model and the visual 2D method was 64%. In the measurement of the end-diastolic volume, there was a remarkable agreement between the 3D heart model and both the Simpson biplane and 3D full-volume methods (98% and 95%, respectively). Similarly, in the measurement of the end-systolic volume, the rate of agreement between the 3D heart model and both the Simpson biplane and 3D full-volume methods was 91% and 92%, correspondingly.

This study showed that the use of the 3D heart model and the Simpson biplane method was more accurate in the study of the left ventricular ejection fraction than that of the visual 2D and 3D full-volume methods. It appears that the use of all 3 methods (ie, the Simpson biplane, 3D full volume, and 3D heart model) in the measurement of the end-systolic and end-diastolic volumes is reliable. (Iranian Heart Journal 2020; 21(2): 41-47)

Despite the great progress in the surgery of complex congenital heart diseases, there is still concern regarding adverse neurological events. We aimed to determine the pre- and on-pump modifiable factors that could predict the neurocomplications after pediatric cardiac surgery.

In a prospective study, modifiable factors such as arterial blood gas, serum lactate, serum glucose, mean arterial pressure, and nasopharyngeal temperature were measured before and during cardiopulmonary bypass (CPB). Moreover, the CPB time, the aortic cross-clamp time, and the deep hypothermic circulatory arrest time were recorded. If there were adverse neurological complications, brain computed tomography scan was done.

435 patients with congenital heart diseases that underwent cardiac surgery, 364 patients at a mean age of 22 months were enrolled in the study. Thirty-three (9%) patients had adverse early-onset neurological events. Seizure and hemorrhage were the most common clinical and neuroimaging findings, respectively. Although the pre-pump oxygen saturation (P = 0.03), the blood CO2 level (P = 0.04), and the serum glucose level (P = 0.03) showed statistical significance in the univariate analysis, the only predictive variables of neurocomplications in the multivariate analysis of logistic regression were the on-pump serum glucose level (P = 0.001) and the nasopharyngeal temperature (P = 0.004).

Among several modifiable factors exerting an influence on the neurological outcome of children undergoing cardiac surgery, special attention should be paid to the control of the intraoperative serum glucose level and the provision of the optimal cooling temperature. (Iranian Heart Journal 2020; 21(2): 48-56)

Heart failure (HF) is one of the most prevalent cardiovascular disorders. Patients with HF need self-care behaviors and, thus, need to be equipped with health literacy to make informed decisions. This study aimed to evaluate health literacy among patients with HF hospitalized in Shahid Mohammadi Hospital, Bandar Abbas, Iran, and its effect on self-care behaviors.

The present cross-sectional correlational investigation was conducted on 192 patients with HF ed via convenience sampling. The data collection instruments were HF health literacy in 3 domains and the European Heart Failure Self-care Behavior scale. The data were analyzed using SPSS, version 23, and descriptive statistics were used along with the Pearson correlation coefficient.

The mean score of health literacy and self-care was 34.6 and 30, respectively. A statistically significant correlation was found between the functional dimension of health literacy and self-care. Thus, a higher health literacy rate was associated with more self-care efforts. The mean score of health literacy varied among the subjects with different education levels.

Considering the statistically significant relationship between health literacy and self-care, it is essential to pay attention to the promotion of the whole dimension of health literacy among patients with HF, especially those of lower education levels, in order to improve their level of self-care. Effective interventions are required to improve patients’ skills in the critical analysis of information and to promote their power of making therapeutic decisions. (Iranian Heart Journal 2020; 21(2): 57-63)

Blood transfusion is needed in patients following open-heart surgery; however, it may lead to the incidence of infection, increased mortality, and longer hospitalization. This study was designed to evaluate the outcome of blood transfusion in patients who underwent cardiac surgery.

The present study enrolled 784 candidates for open-heart surgery at our tertiary care center between April 2012 and 2013. The study outcomes were defined as sepsis, mediastinitis, pneumonia, mortality, extubation times more than 8 hours after surgery, and intensive care unit (ICU) lengths of stay of more than 3 days.

There was a significant association between packed cell transfusion and the incidence of pneumonia, sepsis, prolonged intubation times, surgical site infections, and prolonged lengths of ICU and hospital stay (P < 0.05); however, there was no significant association between packed cell transfusion and mortality (P = 0.2). There was a significant relationship between fresh frozen plasma transfusion and the incidence of all types of surgical complications, mortality, and prolonged ICU and hospital lengths of stay (P < 0.05). There was a significant association between platelet transfusion and the incidence of pneumonia, mediastinitis, prolonged intubation times, surgical site infections, and prolonged lengths of ICU and hospital stay (P < 0.05); nonetheless, there was no significant association between platelet transfusion and mortality (P= 0.1). In the multiple logistic regression, an association was observed between age, sex, and complications following adjustments for packed cell transfusion, fresh frozen plasma, and platelet.

The administration of blood and hemo-components was associated with the development of postoperative complications such as sepsis, mediastinitis, pneumonia, mortality, prolonged intubating times, and prolonged lengths of ICU and hospital stay. (Iranian Heart Journal 2020; 21(2): 64-70)

The aim of the present study was to evaluate the incidence of menstrual bleeding in women undergoing cardiac surgery with cardiopulmonary bypass.

This cross-sectional study recruited 200 women aged 11 years or older (post- menarche) who were scheduled electively for their first cardiac surgery (coronary artery bypass, valve, or congenital). The menstruation status of the patients before and after surgery was assessed. Additionally, the demographic and clinical parameters, as well as postoperative drainage and blood product transfusion, were compared between the patients with and without perioperative menstrual bleeding.

Five (2.5%) women had menstrual bleeding before surgery and 17 (8.5%) experienced vaginal bleeding after the operation. All of these 22 vaginal bleeding cases were self-limited, and there was no need for gynecological intervention. There were no statistically significant differences between the 22 women with vaginal bleeding and the 178 women without vaginal bleeding regarding background clinical variables, blood product transfusion, and postoperative drainage (380 ± 278 vs 500 ± 469 mL; P = 0.242).

Perioperative vaginal bleeding in women undergoing cardiac surgery is not uncommon. However, this finding is self-limited and does not increase postoperative drainage or blood product transfusion. (Iranian Heart Journal 2020; 21(2): 71-76)

Despite the widespread use of different imaging and provocative protocols for heart disease, diagnosis and treatment remain a serious concern. Thus, we aimed to evaluate global longitudinal strain (GLS) among healthy Iranian women aged between 20 and 60 years.

In this cross-sectional study, 360 healthy Iranian women were enrolled. Transthoracic echocardiography was performed for all the subjects to evaluate GLS and global circumferential strain (GCS). These values were compared between the subjects based on age groups.

The mean GLS and GCS values were −20.95 ± 2.32% and −20.71 ± 1.81%, respectively. GLS and GCS had significant negative correlations with age (r = 0.813, P < 0.001 and r = 0.837, P < 0.001). Moreover, GLS was significantly low in the 50–60 age group (−17.22 ±0.71%) and high in the 20–29 age group (−22.73 ± 1.39%), (P = 0.001). Furthermore, GCS was significantly low in the 50–60 age group (−17.92 ± 0.42%) and high in the 20–29 age group (−21.99 ± 0.86%), (P = 0.001)

In the present study, normal GLS and GCS values were associated with the subjects’ age insofar as normal GLS and GCS ranges were lower in the older age groups, as GLS and GCS ranges were higher in the lower age groups (20–29 y). (Iranian Heart Journal 2020; 21(2): 77-83)

A 60-year-old man presented with typical chest pain of the New York Heart Association function class III. The patient mentioned a history of stroke, hypertension, hyperlipidemia, and gastrointestinal bleeding. Angiography revealed a total cut in the mid-portion of the left anterior descending (LAD), a total cut in the ostial portion of the second branch of the diagonal branch of the left circumflex artery (LCX) as well as significant segmental stenosis in the mid-portion of the LCX, and also a significant lesion in the mid-portion of the right coronary artery (RCA). He was scheduled for a multivessel percutaneous coronary intervention (PCI). The LAD was wired with a 0.014-PILOT 150 guidewire, and 2 drug-eluting stents were deployed in the LAD. Six weeks later, the patient experienced chest pain again, despite receiving full medical treatment. The next angiography showed an unexpected pseudoaneurysm, in the mid-portion of the LAD exactly at the site of the stenting performed in the previous PCI. We considered coronary artery bypass grafting given the high possibility of thrombosis in the LAD and the presence of lesions in the RCA and the LCX. Conclusions Coronary aneurysms, albeit rare after PCI, can be life-threatening complications. Early diagnosis can be lifesaving. Chest pain after any intervention should flag up complications, especially in the absence of response to medical treatment. Regular follow-ups are the key to the diagnosis of any complications in the golden time for treatment. (Iranian Heart Journal 2020; 21(2): 84-89)

A 53-year-old woman was referred to us with frequent episodes of palpitation, near-syncope, and dizziness. The patient had a history of apical hypertrophic cardiomyopathy in her sister and aborted sudden cardiac death in her aunt. Because of first-degree atrioventricular block and high atrioventricular Wenckebach point, cardiac magnetic resonance imaging was done, and apical hypertrophic cardiomyopathy was diagnosed. (Iranian Heart Journal 2020; 21(2): 90-93)