Iranian Heart Journal
Volume:4 Issue: 4, Spring 2003

Background: 

Heart Valve homografts have been used in reconstructions of right and ‎left ventricular outflow tract (RVOT and LVOT) for nearly 50 years now with ‎varying results.

Methods: 

The outcome of homograft implantation was analyzed in ‎‎101 patients who received 108 cryopreserved homografts for the reconstruction of ‎RVOT and LVOT between April 1993 and March 2003‎‏.‏

Results: 

88.2% aortic valve and 11.7% pulmonic valve homografts were used. ‎Median age at implantation was 10.0 years (Mean: 13.1 ± 10.6 years, range: 5 months ‎to 57 years). Endpoints included: (1) patient survival, (2) homograft failure (valve ‎explant or late death) and (3) homograft dysfunction (homograft insufficiency or ‎homograft stenosis). Mean follow up duration was 2.9 ± 2.4 years. There were 11 ‎homograft dysfunctions requiring reoperation with the mean longevity of 4.4 ± 2.3 ‎years. We had only one late death due to congestive heart failure (CHF), and all the ‎other deaths (23.7% of the patients) occurred perioperatively. The quality of life of ‎most of the survivors is good‏.‏

Conclusion: 

Early and mid-term results of homograft implantation are good, but long-‎term results remain to be investigated (Iranian Heart Journal 2003; 4 (4):6-15‎‏).

Background: 

In angioplasty of chronic total occlusion, categorizing lesion ‎characteristics may be useful for their impact on procedural success. There is ‎controversy about the role of bridging collateral vessels in chronic total occlusion ‎procedural outcomes. This study investigated the effect of bridging collateral vessels ‎on the success of coronary angioplasty in patients with chronic total occlusions‏.‏

Methods: 

Seventy-seven consecutive patients undergoing coronary angioplasty for ‎chronic total occlusion were classified into two groups. Group I patients had chronic ‎total occlusion with bridging collateral vessels (27 patients), and patients in group II ‎had no such vessels (50 patients‏).

Results:

Procedural success was achieved in 11 patients in group I and in 41 patients ‎in Group II (40.7% vs. 82%; p=0.0002; relative risk 3.9; 95% confidence interval 1.7 ‎‎- 6.4). Of 52 patients with successful angioplasty, patients with an estimated duration ‎of occlusion of less than 3 months had more successful results than patients with ‎occlusions of over 3 months (63.5% vs. 47.5%; p=0.0001; relative risk 1.8; 95% ‎confidence interval 1.3-2.6). The presence of a side branch 2mm or less from the ‎occlusion point was a predictor of an unsuccessful result (p=0.0007; relative risk 2.9; ‎‎95% confidence interval 1.5-5.6‎‏).

Conclusion: 

There are some morphologic variables which may be useful in guiding ‎angioplasty in patients with chronic total coronary occlusion. Presence of bridging ‎collateral vessels is one of them, which appears to be inversely related to procedural ‎success (Iranian Heart Journal 2003; 4 (4):16-21‎‏).

Background: 

An elevated arterial pressure is probably the most important public ‎health problem in developed countries. Although the measurement of blood pressure ‎in the clinic has been the cornerstone of the diagnosis and management of ‎hypertension, it has some limitations. Ambulatory blood pressure monitoring (ABPM) ‎is a method of blood pressure assessment which compensates for some of the ‎limitations and errors of clinical values such as the white coat phenomenon.‏

Methods: 

In this cross sectional study, we enrolled 42 (20 male, 22 female) ‎hypertensive patients who were under treatment. Each patient s BP was measured in ‎clinic twice at 5minute intervals. ABPM having been set up, each patient s blood ‎pressure was measured at 30- minute intervals during the day and 60- minute intervals during the night. The ‎patients were advised to do regular daytime activities and record unusual activities.

‎Results: 

The mean clinic BP 137.95±14.28/88.66±9.53 (mmHg) compared with a ‎mean awake ambulatory BP (ABP) of 132.90±12.27/80.51±7.39 (mmHg). A white ‎coat effect (Clinic-Ambulatory BP > 20/15mmHg) was present in 33.3% (19.15%-‎‎47.55%, CI 95%) of the individuals. The correlation coefficient of systolic pressure, ‎diastolic pressure and heart rate between clinic and awake ambulatory measurements ‎was 0.55, 0.48 and 0.57, which indicated a linear relationship (P<0.001). Multiple ‎regression models showed that age, gender, occupation and the duration of ‎hypertension (by year) after diagnosis have no significant effects on estimating awake ‎ABP by clinical measurements but could lead to a better estimation‏.‏

Conclusion:

The frequent occurrence of white coat phenomenon in these patients ‎suggests that clinic BP assessment may not always represent usual awake ambulatory ‎BP in patients receiving antihypertensive therapy. We also suggest that physicians ‎who do not have the availability of ABPM use this model to estimate average awake ‎BP by clinic BP measurements: awake systolic BP (mmHg)=0.52 x clinic systolic BP ‎‎+ 66; awake diastolic BP (mmHg) = 0.46 x clinic diastolic BP + 42; and awake heart ‎rate (p/min) _ 0.33 x clinic heart rate + 52(Iranian Heart Journal 2003; 4 (4):25-30‎‏).

Background: 

Electrocardiography is one of the oldest, easiest, simplest and most ‎important inexpensive paraclinical tools in cardiology. Being able to use this easy ‎method with enough sensitivity would be a great aid to the cardiologist in evaluating a ‎common problem like congestive heart failure (CHF‏).

Method: 

Two hundred cases with left bundle branch block (LBBB) were chosen and ‎divided into two groups: QRS duration less than 120msec in the first group, and more ‎than 120msec in the second group. Left ventricular ejection fraction (LVEF) was ‎studied by 2D, M-mode and Doppler echocardiography as an index of LV systolic ‎function‏.‏

Results: 

In cases with QRS duration less than 120msec, LVEF averaged between 40-‎‎50%. In the other group with QRS duration more than or equal 120mseconds, LVEF ‎was between 30-40%. Finally, when QRS duration exceeded 160msec, almost all of ‎the patients had LVEF less than 30%‎‏

.‏Conclusion: 

LV systolic function could be estimated with an acceptable sensitivity by ‎observing surface ECG in LBBB cases. This observation may lead to conceptual ‎support for attempts at normalizing QRS duration by biventricular or multi-site ‎ventricular pacing in patients with severe LV systolic dysfunction (Iranian Heart ‎Journal 2003; 4 (4):31-34‎‏).

Background: 

Coronary artery fistula (CAF) is a rare congenital anomaly that can be ‎complicated by endocarditis, myocardial infarction or coronary aneurysms. The ‎purpose of this article is to review the clinical characteristics and surgical outcome in ‎‎10 patients with CAF‏.‏‎‎

Methods: 

From 1990 to 2000, ten patients (aged 6 months to 15 years with a mean of ‎‎8.5 years) were diagnosed with CAF via echocardiography and cardiac ‎catheterization. Six were female and 4 were male. All the patients with isolated CAF ‎‎(9) were asymptomatic. One patient with associated anomaly (MVP with severe MR) ‎had dyspnea on exertion and palpitation‏.‏‎‎

Results:

Five fistulas originated from the right coronary artery, three from the left and ‎two from the left circumflex. Drainage was to the right ventricle (7), right atrium (2) ‎and pulmonary artery (1). The ratio of pulmonary to systemic flows ranged between 1 ‎to 1.6. All the patients had surgical ligation. In the symptomatic patient, in addition to ‎ligation, mitral valve replacement was performed. There was no operative or late ‎death. Follow-up evaluation ranging from 1 year to 6 years with a mean of 4.2 years ‎showed no evidence of recurrent or residual CAF‏.‏‎‎

Conclusion:

Surgical management of CAF is a safe and effective treatment, resulting ‎in 100% closure rate (Iranian Heart Journal 2003; 4 (4):35-38).‎

Background: 

The month of Ramadan is the ninth lunar month of the Islamic calendar, ‎during which every year millions of Muslims fast from sunrise to sunset. These ‎fasting episodes are associated with changes in sleeping pattern, medication timing, ‎and extra prayers at night, etc. The goal of this work was to evaluate the safety of ‎Ramadan fast with respect to blood pressure for treated hypertensive patients‏.‏‎‎

Method:

This study included 21 controlled hypertensive patients on single or twice-‎daily medications; each volunteered to perform 24-hour ambulatory blood pressure ‎monitoring (ABPM) twice: during Ramadan and 2 months after Ramadan during a ‎non-fasting day. Mean average awake/asleep and 24-hour blood pressure, also systolic ‎and diastolic load, dipper vs. non-dipper were compared between the two groups‏.‏

Result:

There were no significant changes between any of these variables (P=1.00) in ‎the two measurement periods‏.‏‎‎

Conclusion:

It seems that treated hypertensive patients can be safely assured that with ‎the continuation of pervious medication(s), Ramadan fast can be observed without the ‎need for further work up (Iranian Heart Journal 2003; 4 (4):39-43).‎

Background: 

Coronary artery diseases are the leading cause of death in the ‎developing countries, including Iran. Continued advances in medical and surgical ‎techniques, combined with effective and focused programs in cardiac rehabilitation, ‎are critical to reduce the overall incidence of coronary artery diseases. Now it is ‎recommended that all survivors of acute myocardial infarction receive antiplatelet ‎drugs, beta-adrenergic blocking agents, ACE inhibitors and statins. However, studies ‎show that the ratio of prescribing these drugs is far lower than ideal. This study has ‎been designed to evaluate these ratios in Iran‏.‏‎‎

Methods: 

In a descriptive, cross-sectional retrograde study, the ratio of prescribing the ‎above-mentioned drugs in 912 randomly selected patients from Shiraz University ‎hospitals who met WHO criteria for myocardial infarction from March 2000 to March ‎‎2001 were studied. Trained medical students recorded demographical data, location of ‎infarction, risk factors and pharmacologic therapy at the time of the discharge of the ‎patients from the medical recording files in a standardized questionnaire‏.‏‎‎

Results: 

The mean age of the studied patients was 61±12 years. The most frequently ‎prescribed drugs were antiplatelet agents and the least frequent ones were statins. ‎There were statistically significant relationships between cigarette smoking and beta-‎adrenergic blocking agents administration, hyperlipidemia and statins administration ‎and hypertension and ACE inhibitors administration‏.‏‎‎

Conclusion:

There is a need for improvement in secondary prevention in patients with ‎myocardial infarction at the time of hospital discharge, and risk factor evaluation and ‎suitable drug therapy is necessary for secondary prevention in Shiraz University ‎hospitals (Iranian Heart Journal 2003; 4 (4):44-48).‎

Left or biventricular (BiV) pacing, or cardiac re synchronization therapy (CRT) is a ‎new treatment for patients with advanced congestive heart failure (CHF) and left ‎bundle branch block (LBBB). This therapy is based on the theory that synchronous ‎BiV pacing is able to reduce atrioventricular (AV), inter- and intraventricular ‎dyssynchrony (DYS). Although there is convincing evidence that CRT increases the ‎left ventricular ejection fraction (LVEF), decreases mitral regurgitation (MR), and ‎improves symptoms caused by heart failure, and reduces combined end points of all-‎cause mortality and hospitalization, the proportion of non responders (NR) to this ‎therapy has been described and high as about one third to one half of patients with ‎heart failure and LBBB. Here we review factors that may be responsible for this ‎relatively high prevalence, and the ways for more accurate patient selection (Iranian ‎Heart Journal 2003; 4 (4):49-‎‏.‏‎56).‎

Background:

Scientists have long been puzzled by the fact that many heart attacks ‎occur in patients who do not have any predisposing factors such as high blood ‎pressure, smoking, and high cholesterol, and they have always wanted to ascertain ‎what causes these heart attacks. The answer, according to some, may lie not merely in ‎physiology but behavior. In the last 30 years, a small group of scientists has held ‎steadfastly to the hypothesis that the way people think, feel, and act as they cope with ‎the daily stresses of life can have a profound and some times deadly- effect on their ‎heart. In this study we wanted to evaluate the patient s personality profile before ‎angiography or heart surgery‏.‏‎‎

Methods:

Two hundred and ten patients who needed angiography or heart surgery ‎were selected to complete the following questionnaires - SCL 90 personality test, ‎general knowledge, demographic questionnaire, and surgical questionnaire‏.‏

Results:

The personality traits of patients are susceptible to change before ‎angiography and heart surgery, but according to the GSI standard, these changes are ‎limited to the neurotic phase‏.‏‎‎

0Conclusion:

The presence of psychiatrists and clinical psychologists are useful and the ‎employment of psychotherapy, psychoanalytic techniques, and education of patients ‎can maximize the result of heart surgery as well (Iranian Heart Journal 2003; 4 (4):57-‎‎59).‎

Background:

Atherosclerosis is a generalized process of vessels which involves ‎coronary arteries and carotid vessels in a similar fashion. In this study we evaluate the ‎relationship of coronary artery disease (CAD) with intima-media thickness (IMT) of ‎carotid vessels and carotid artery stenosis‏.‏‎‎

Methods:

120 patients were subdivided into four groups: normal coronary; single ‎vessel (SVD) and two-vessel (2VD); and three-vessel disease (3VD), established by ‎means of coronary angiography. The groups were then prospectively evaluated with ‎color duplex ultrasound (CDUS) examination during a 1-year period to assess the ‎relationship of carotid artery stenosis and intima-media thickness (IMT) with CAD‏.‏

Results:

from the 120 patients who underwent examination, two cases showed above ‎‎75% carotid stenosis, and 62.8% of the patients with three vessel disease exhibited ‎more than 1.2 mm intima-media thickness with p value < 0.001‎‏.‏ ‎‎

Conclusions:

We have not found a statistically significant relationship between ‎significant coronary artery disease and carotid artery stenosis but a remarkable ‎correlation with the degree of coronary artery disease and increased intima-media ‎thickness. Auscultation of a bruit in the neck is not a reliable indicator of carotid ‎artery Stenosis (Iranian Heart Journal 2003; 4 (4):60-62‎‏(.‏

Background:

Digoxin prescription with an interruption of one or two days a week is ‎frequently used in Iran. We compared this kind of digoxin prescription with an ‎uninterrupted one through the determination of serum digoxin level and clinical ‎response in Iranian patients‎‏.‏

Methods:

This study was designed as a crossover clinical trial on 28 patients suffering ‎from chronic atrial fibrillation (AF), and the two different methods of digoxin ‎prescription were compared through achieving therapeutic range of serum digoxin ‎level and clinical response as control of heart rate in patients with chronic AF‏.‏

Results:

The serum digoxin concentration in interrupted consumption, the day before ‎‎(0.885 ± 0.29 ng/ml) and after (0.614 ± 0.35 ng/ml) interruption was significantly ‎lower than the continuous form (1.157 ± 0.3 ng/ml), p < 0.05. About 35% of the ‎patients in the interrupted schedule of digoxin had plasma levels lower than 0.8 ng/ml ‎‎(minimum therapeutic range), compared with no one in the continuous schedule. Also ‎none of the patients in the continuous consumption group showed clinical and/or ‎electrocardiographic signs of digoxin toxicity. The mean heart rate in interrupted use ‎on the day before (84.82 ± 7.2 beats/min) and after (86.5 ± 3.8 beats/min) interruption ‎was significantly higher than that in the continuous form (75.9 ± 5.2 beats/ min), p < ‎‎0.05‎‏.‏ ‎‎

Conclusion:

This study showed that the continuous use of digoxin has the advantage ‎of achieving the therapeutic range and better controlling the heart rate in patients with ‎AF rhythm and could be the preferred form of prescription in the majority of our ‎patients, as it is in nearly all the countries around the world (Iranian Heart Journal 2003; 4 ‎‎(4):6367).‎

Objective: 

Idiopathic dilated cardiomyopathy (IDCM) is currently an important cause ‎of mortality and morbidity due to chronic heart failure. The aim of our study was to ‎assess whether there could be any clinical and /or echocardiographic improvement in ‎patients with IDCM who had undergone treatment of recombinant human growth ‎hormone (GH).‎ ‎‎ ‎.

Methods: 

Fourteen patients with IDCM and moderate heart failure (e.g. New York ‎Heart‏ ‏Association functional class II-III) were studied at base line, immediately and ‎‎3-months after treatment with GH. The study was a double-blind clinical trial. ‎Traditional treatment (e.g. digoxin, ACEI, B-blocker and diuretics) was continued ‎during the study. Cardiac performance was evaluated with clinical and ‎echocardiographic examinations.‎ ‎

Results: 

In spite of statistical improvements in the left ventricular ejection fraction ‎‎(LVEF)(mean ±SD from 35.6±5.9% at the base line of this study to 39.6%f6.7% ‎immediately and 39.3%f7.9% three months after treatment, p value <0.05), other data ‎of the clinical and echocardiographic findings were not significantly different between ‎base line and post-treatment‏.‏‎‎

Conclusion:

We conclude that 3-months of GH therapy in patients with idiop thic ‎dilated cardiomyopathy had little beneficial effects on cardiac mass and performance ‎‎(Iranian Heart Journal 2003; 4 (4):68-71‎‏(.‏

Dynamic left ventricular outflow tract (LVOT) and mid-cavitary obstruction has been ‎associated with hypertrophic obstructive cardiornyopathy. . Acute LVOT and mid - ‎cavitaryobstruction has been described as a complication of myocardial infarction ‎‎(MI). In the latter situation, this unusual form of dynamic obstruction occurs as a ‎result of compensated hyperdynamic basal wall motion in patients with apical ‎infarction. We describe a patient who developed mid-cavitary obstruction following ‎silent anteroseptal MI.

A case of left atrial appendage (LAA) aneurysm misdiagnosed previously as partial ‎pericardial defect is presented. This previously totally asymptomatic young ‎multiparous woman was referred to us because of intermittent sharp chest pain and an ‎abnormal CXR. Complementary imaging modalities revealed a large mass behind the ‎left ventricle causing anterolateral hypokinesis. Although relatively symptomless, ‎because of potential hazardous complications such as paroxysmal supraventricular ‎tachycardia, syncope, sudden cardiac death, embolic phenomena and strangulation, ‎the patient s LAA aneurysm was resected shortly after the confirmation of diagnosis. ‎The postoperative course has been uneventful, and she is currently asymptomatic ‎.