Iranian Heart Journal
Year:2020 | Volume:21 | Issue:1|Papers Count:14

Background: Early vein graft occlusion after coronary artery bypass grafting (CABG) is one of the major problems after the surgery which directly impacts its short-and long-term outcomes. One of the potential explanations is aspirin resistance. The aim of this study was to evaluate the efficacy and safety of dual antiplatelet therapy (DAPT) with clopidogrel and aspirin compared with aspirin alone on the reduction of early graft occ usion. Methods: In a multicenter randomized controlled trial with a parallel design, from 2012 to 2015 among 1165 patients, we compared 140 candidates for CABG: 71 in the DAPT group (300 mg c of clopidogrel and 80– 325 mg of aspirin) and 69 in the aspirin group. The primary outcome was graft patency assessed by coronary computed tomography angiography performed at 6 months’ follow-up. Bleeding complications were considered the secondary outcome. Results: Saphenous vein grafts were occluded in 10 (14. 1%) patients in the DAPT and 11 (15. 9%) in the control group (P = 0. 758). After adjustments for study centers, the associations remained unchanged (OR [95% CI]: 1. 49 [0. 59– 3. 74]). Bleeding endpoints were also similar in the 2 groups (P > 0. 05). Conclusions: Our study did not demonstrate the superiority of the DAPT regimen over aspirin monotherapy in patients undergoing elective CABG. Larger multicenter studies may provide more evidence.

Background: Cardiac tamponade nearly always requires urgent intervention, but the optimal management of pericardial effusion is still controversial. The aim of our study was to introduce the profile and treatment results of patients with tamponade in our referral heart center. Methods: From November 2010 to November 2014, our retrospective study was performed on 220 patients with tamponade. All the clinical and echocardiographic findings of the patients, as well as their operative and follow-up data, were recorded and analyzed. Results: The overall prevalence of tamponade relative to the entire study population undergoing heart surgery was 8. 5%. There were 106 men and 114 women at a mean age of 55. 5 years (range = 5– 99). The most common causes of tamponade were cardiac diseases (21%), malignancy (20. 4%), unknown (20. 4%), chronic renal failure (15%), and post-cardiac surgery complications (10. 5%). The approaches for pericardial effusion drainage were the subxiphoid approach (97. 7%), mini-thoracotomy (1. 4%), and percutaneous pericardiocentesis (0. 9%). The intraprocedural mortality rate was zero, the mortality rate during hospital stay was 4. 5%, and the recurrence rate was 9. 1%. Patients with primary sanguineous pericardial effusion, malignant etiologies of tamponade, and malignant pericardial effusion had significantly poor survival. The survival rates at 1 month, 1 year, 2 years, and 3 years were 87. 1%, 67. 7%, 64. 5%, and57. 2%, respectively. Conclusions: We found an association between left pleural effusion and small amounts of pericardial effusion, hence the necessity of more attention in the echocardiographic evaluation of these patients. The subxiphoid approach for pericardial effusion drainage is a safe and simple procedure associated with relatively lower postoperative complications, mortality, and recurrence rate. Sanguineous pericardial effusion is concomitant with poor prognoses.

Background: β-thalassemia is the most common monogenic disease caused by abnormalities in the synthesis of the β-chain of hemoglobin. Methods: From January 2018 to September 2018, 90 patients (age >18 y) with β-thalassemia major or intermedia who referred to Rajaei Cardiovascular, Medical, and Research Center, Tehran, Iran, for the assessment of myocardial iron overload were enrolled. All the patients were receiving regular blood transfusions and chelating therapy. Comprehensive transthoracic echocardiographic studies consisting of 2D echocardiography, tissue Doppler imaging, and real-time 3D echocardiography were performed. Results: A total of 90 patients were enrolled in the study. Cardiac iron toxicity (ie, T2* < 20 ms) was seen in 28 (31%) patients; whereas in 62 (69%) patients, the cardiac iron level was undetectable (ie, T2* > 20 ms). Patients with T2* < 20 ms had significantly higher serum ferritin levels than those with T2* > 20 ms (P = 0. 02). No significant correlation was found between the serum ferritin level and T2* (r = − 0. 08, P = 0. 41). The left ventricular ejection fraction was statistically similar in the 2D and 3D examinations. Left atrial endsystolic and end-diastolic volumes were greater in the patients with iron cardiotoxicity than in those with no detectable cardiac iron deposition (P = 0. 01 and P <0. 001, respectively). Left atrial strain was also significantly lower in the patients with critical iron overload. The patients with T2* < 20 ms also had lower left atrial ejection fractions than those with T2* >20 ms, both in 2D and 3D examinations (both Ps <0. 001). Conclusions: Our study showed that changes in the left atrial structure and function precede impairment in the left ventricular systolic function in thalassemia patients with critical myocardial iron loading.

Background: Heart failure is a complex syndrome and also one of the common reasons for readmission following discharge. This condition imposes an enormous economic burden on healthcare sectors. The present research aimed to study the establishment of a home care system for patients with heart failure in order to evaluate the cost-effectiveness of this system and patient satisfaction. Methods: The present health system research selected 40 patients as the sample with eligible criteria. Care was provided by nurses based on physicians’ instructions. In the first visit at home, a questionnaire on the quality of life was filled out by the patients or the nurses. The financial data of the medical records of the patients constituted the reference for the analysis of cost. After the intervention, the questionnaire on the quality of life was filled out by the patients once again and their satisfaction was measured. The data were statistically analyzed using the Python programming language and SPSS-16 at the 0. 05 level of significance. Results: The length of stay in the hospital for each patient decreased from 2. 1 days to 0. 9 days per month. The number of annual hospitalizations also decreased from 5 to 3, and the number of annual outpatient visits showed a reduction from 46 to 38 for each patient. The results of the patient satisfaction assessment also indicated that most of the patients were satisfied with the services provided to them. Conclusions: The results showed that our study was cost-effective. We suggest that interventions be performed on larger scales so that the results can be used in the future as services available to patients with heart failure.

Background: This prospective case-series study was conducted to determine the predictive power of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on shortand long-term outcomes in patients with pulmonary thromboembolism (PTE). Methods: Ninety-two patients (age = 60 ± 1. 97 y, 54. 7% male) diagnosed with PTE were recruited. NT-proBNP levels and echocardiographic indices were measured and recorded. The primary endpoint was considered to be 3-month PTE-related deaths and long-term adverse outcomes including 1-year all-cause mortality, rehospitalization due to the recurrence of PTE, right ventricular dysfunction, and pulmonary hypertension. Results: The serum NT-proBNP level and the right ventricular diameter were significantly higher in the patients with adverse outcomes than in the outcome-free patients. Several significant correlations were found between NT-proBNP levels and echocardiographic indices. During a mean follow-up time of 12 months, 1 patient suffered PTE relapse, 15 patients had right ventricular dysfunction and pulmonary hypertension, and 2 patients expired. Age was an independent value in the prediction of the adverse outcome (OR: 1. 064, 95% CI: 1. 01 to 1. 11). Discharge NT-proBNP levels, calculated according to a multiple cutoff point strategy for heart failure, in the PTE patients with adverse outcomes was 2. 36 fold that in the outcome-free patients. The optimal value for discharge NTproBNP according to the receiver operating characteristic analysis was 327 pg/mL, with a sensitivity of 80% and a specificity of 43%. Conclusions: NT-proBNP measurement during the course of PTE, especially on discharge, may have a role as an easy-to-use diagnostic tool for determining patients with poor prognoses.

Background: This study aimed to determine irisin serum levels in type 2 diabetic patients with and without coronary artery disease (CAD). Methods: This study was performed on 56 type 2 diabetic patients with and without CAD and 28 normal controls. The serum levels of irisin, HbA1c, and fasting blood sugar of all the participants and the severity of CAD in the diabetic patients were determined. Results: The irisin serum level was significantly decreased in the CAD diabetic patients who were symptomatic. HbA1c had a moderate positive correlation with the SYNTAX score in the diabetic patients with CAD. The serum level of irisin was not significantly different between the evaluated groups. Conclusions: Based on the results, decreased irisin may be considered a risk factor for type 2 diabetic patients with CAD. Accordingly, the evaluation of patients with decreased irisin serum levels regarding the prediction of heart infarcts may be valuable.

Background: Blunted heart rate response (BHR) during dipyridamole stress testing has been reported to be related to higher cardiac death. This study was performed to assess the association between BHR and perfusion abnormalities in diabetic patients undergoing dipyridamole stress ECG-gated myocardial perfusion imaging (MPI) as compared with nondiabetic patients. Methods: A total of 2172 subjects (1602 women and 570 men) at a mean age of 61 ± 11 years who were referred for MPI to our department were studied. The subjects were divided into 2 groups on the basis of the presence or absence of diabetes mellitus (849 diabetic vs 1323 nondiabetic subjects). Results: Dipyridamole-related BHR was noted in 471 (67. 7%) patients, demonstrating a significantly higher incidence in the diabetic patients than in the nondiabetic subjects (P < 0. 05). Both basal systolic and peak systolic blood pressures were significantly higher in the patients with diabetes mellitus (P < 0. 05). However, no significant difference was noted in the number of segments with perfusion abnormalities in patients with BHR as compared with the subjects with a normal hemodynamic response, neither in the diabetic nor in the nondiabetic subjects. Conclusions: The results of our study suggest that the presence of myocardial perfusion abnormalities and left ventricular dysfunction is not related to abnormal heart rate response during dipyridamole stress testing, neither in diabetic nor in nondiabetic subjects. The incidence of BHR to dipyridamole is significantly higher in diabetic patients, however.

Background: This study aimed to evaluate the relationship between exposure to PM2. 5 and the number of hospital admissions due to cardiovascular diseases. Methods: The present time-series, case-crossover study is a part of the CAPACITY study on patients admitted to 15 hospitals in the Iranian city of Isfahan because of cardiovascular diseases in 2012. PM2. 5 concentrations were calculated in air pollution monitoring stations and divided into 3 groups of good or moderate, unhealthy for sensitive people, and unhealthy or hazardous. The relationship between the number of admissions and fine particle concentrations was assessed. Results: This study evaluated 15752 participants at a mean age of 59 ± 19. 4 years. Men accounted for 52. 6% (n = 8282) of the study population. The mean concentration of fine particles was 53. 77 ± 29. 65 micrometers. In most days of the year, the concentration of PM2. 5 was at an unhealthy level for sensitive people. Poisson regression analysis showed a significant correlation between the number of hospital admissions due to cardiovascular diseases and ischemic heart diseases and fine particle concentrations in the unhealthy level for sensitive people (P = 0. 001, P = 0. 001, and P = 0. 002). There was a significant correlation between PM2. 5 concentrations and the number of admissions due to conductive heart diseases and heart blocks in unhealthy or hazardous levels (P = 0. 02 and P = 0. 04). Conclusions: The number of hospital admissions due to cardiovascular diseases can increase during air pollution, especially when the concentrations of PM2. 5 are elevated.

Background: Diabetes mellitus (DM) is associated with several comorbidities and complications such as hypertension, obesity, hyperlipidemia, nephropathy, and cardiovascular diseases. This study aimed to investigate the correlation between the left atrial (LA) function and DM via conventional and speckle-tracking echocardiography (STE). Methods: In this prospective study, from 198 patients with sinus rhythms, 174 patients were included based on inclusion and exclusion criteria. Conventional and STE examinations were done for all the patients. The patients’ demographics, comorbidities, and family history, as well as the results of their angiography or computed tomography angiography, electrocardiography, and echocardiography, were recorded. The variables were compared between the groups with and without DM, and the association between the LA function and DM was studied in the patients. Results: Totally, 45. 2% of the diabetic patients (n = 28) and 38. 4% of the nondiabetic patients (n = 30) had diastolic dysfunction (P = 0. 384). The diabetic patients had a lower mean of the left ventricular end-diastolic diameter, the LA peak strain during the reservoir phase, the LA pump, and the LA peak positive strain rate during ventricular systole (all Ps < 0. 001) and a higher mean of the left ventricular mass index, the A-wave, the E/A, the LA peak negative strain rate during early diastole (all Ps <0. 001), the left ventricular end-systolic volume (P = 0. 001), the Ea (P = 0. 008), the LA ejection fraction (P = 0. 011), and the passive emptying volume (P = 0. 026). Conclusions: The results of the present study indicated LA and left ventricular dysfunction in diabetic patients. However, the LA function may be affected by several factors, and our nonrandomized patient selection could also have affected the results. Thus, it is suggested that future randomized clinical trials compare the LA echocardiographic parameters in matched groups.

Background: Bleeding occurs during and after cardiac surgery, resulting in postoperative anemia. If patients have preoperative anemia, the need for blood transfusion increases. Transfusion is associated with several complications. Methods: In this study, severe anemia was defined as hemoglobin (Hb) < 8 g/dL, moderate anemia was defined as Hb = 8– 10 g/dL, and mild anemia was defined as Hb = 10– 12 g/dL for women and Hb = 10– 13 g/dL for men. In the entire study population, the need for transfusion according to the Hb level and the amount of blood transfusion were evaluated. The study aimed to determine the association between anemia and the patients’ age, sex, type of surgery, and weight. Results: In this study, 306 patients were evaluated in a 3-month period. The mean Hb level of the patients was 13. 1 g/dL (12. 08– 14. 2), and the mean hematocrit level was 39. 5% (36. 17– 42. 15). Anemia was reported in 32. 4% of the patients (Hb < 12 g/dL for women and Hb < 13 g/dL for men). According to the anemia classification, 90. 9% of the anemic patients had mild anemia, 8. 1% moderate anemia, and 1% severe anemia. Of the 306 patients, 68. 6% did not need to receive packed red blood cells. Additionally, of the 207 patients who were not included in the anemia group, 44 (21. 2%) cases received packed red blood cells due to surgical bleeding. However, of the 99 patients who were anemic, 52 (52. 52%) cases needed packed red blood cells. Conclusions: In the present investigation, about one-third of the study population had anemia before surgery and these patients required blood transfusion 2. 5 times more than those without anemia.

Background: The inflammatory nature of rheumatoid arthritis presents a hypothesis on the increase in the likelihood of cardiovascular diseases in patients with rheumatoid arthritis. Recently, the use of speckle-tracking echocardiography to evaluate ventricular strain, especially the global longitudinal strain (GLS), has provided more comprehensive information on ventricular dysfunction in these patients. In the present study, we evaluated changes in the GLS index along with other left and right ventricular parameters in patients with rheumatoid arthritis compared with healthy controls. Methods: The study population was comprised of a case group (patients with rheumatoid arthritis in the active phase during the first 5 years of diagnosis referred to Shariati Hospital without a history of any other diseases) and a control group (individuals without a history of rheumatoid arthritis or cardiac abnormalities referred for clinical check-ups). In both groups, 2D and 3D echocardiographic examinations were performed by a single cardiologist to assess cardiac functional parameters. Results: Comparisons of the echocardiographic indices between the 2 groups showed significantly lower LA (Left Atrium), AO (Aorta), interventricular septal end-diastole (IVSD), Posterior wall diastolic diameter (PWD), and RVsm (Right Ventricular systolic celocity) in the group suffering from rheumatoid arthritis than in the control group. The GLS parameter was significantly lower in the rheumatoid arthritis group than in the healthy group (-19. 5 ± 2. 34 vs-20. 42 ± 3. 07; P = 0. 042); however, there was no difference in the global circumferential strain parameter between the 2 groups (-19. 69 ± 3. 55 vs-20. 49 ± 1. 79; P = 0. 566). In contrast, the mean right ventricular GLS was-18. 77 ± 5. 34 in the case group versus-21. 87 ± 13. 99 in the control group, indicating a significant difference (P = 0. 008). Conclusions: In the echocardiographic assessment of patients with rheumatoid arthritis, a decrease in the ventricular function parameters, especially the GLS, is expected, which may be due to the effect of inflammatory factors on the cardiac ventricular strain.

A 30-year-old woman presented with frequent episodes of paroxysmal palpitation and electrocardiographic evidence of minimal pre-excitation of the left lateral accessory pathway. The patient underwent septostomy, which revealed air bubbles in the left ventricular cavity. Aspiration was done with a pigtail catheter via the retrograde aortic approach. Transient STelevation in the inferior leads was demonstrated. Left-sided hemiplegia was present after consciousness, which was completely resolved after 24 hours.

Guide-wire fracture during percutaneous coronary interventions is a rare and potentially serious complication. Herein, we report a case of guide-wire fracture inside the left main coronary artery following percutaneous coronary intervention in a 58-year-old man. The patient had severe chest pain, and the extraction of the retained guide-wire fragment was thwarted via percutaneous retrieval approaches. Ultimately, he had a successful emergency surgical extraction of THE retained guide-wire fragment and coronary artery bypass graft surgery. This report indicates that the surgical extraction of a retained guide-wire fragment is still safe and the only option for its treatment after the failure of retrieval approaches.

Paroxysmal supraventricular tachycardia (PSVT) is one of the most common arrhythmias, and it occurs in the general population with a good prognosis. PSVT occurs in all age groups, with an incidence rate of approximately 1– 3 cases per 1000 persons. We describe a patient presenting with PSVT and a complaint of hiccups.