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  Most popular articles (Since October 06, 2017)

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Preoperative predictors of postoperative aspiration risk after cardiac surgery
B Jason Bowles, Jo Puntil-Sheltman, Dallas Mullins, Katie M Craig, Jose Benuzillo
October-December 2017, 6(4):24-28
Background: Aspiration is a common complication among hospitalized patients, and patients undergoing cardiac surgery are at increased risk. Our aim was to determine if screening for frailty could identify patients at risk for aspiration. Patients and Methods: A prospective cohort study of patients 65 and older undergoing nonemergent heart surgery at a single community hospital for 1 year was performed. All patients were screened for frailty before surgery using the 5-m walk test. All patients were screened for aspiration before and after surgery using 90-mL water swallow challenge protocol. Preoperative risk factors and postoperative outcomes were analyzed. Results: Of 166 patients studied, 16 (9.6%) were considered frail. Eleven patients (6.6%) failed the swallow screen preoperatively, and 34 patients (20.5%) failed postoperatively. Frail patients were 3.4 times more likely to fail the postoperative swallow screen than their nonfrail counterparts (odds ratio [OR] = 3.36; 95% confidence interval [CI]: 1.42–7.96; P = 0.01). After adjusting for age, comorbidities, and surgical factors, the likelihood of aspiration risk was still three times higher in frail patients (OR = 3.01; 95% CI: 1.06–8.98; P = 0.04). Conclusions: Frail patients are at increased risk of aspiration after cardiac surgery, but frailty screening does not identify all patients at risk. The 90-mL water swallow challenge is a simple and inexpensive test that can be used to identify patients at risk for aspiration.
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Pulse oximetry screening of neonates for congenital heart disease
NB Mathur, Surendra Bahadur Mathur
October-December 2017, 6(4):1-7
We tried to discuss the impact of early diagnosis on outcome of critical congenital heart diseases (CCHDs), current options, and their limitations in timely diagnosis, utility of pulse oximetry screening (POS), current recommendations for screening and challenges in resource constrained countries and to suggest further avenues to cover existing gaps. Evidence acquisition process was performed on the PubMed database and Google scholar for every available article in peer reviewed journals. Prevalence of congenital heart disease (CHD) at birth is estimated to be 8/1,000 live births. About 25% of CHDs are life threatening CCHDs. The current guidelines for POS recommend that all neonates in well newborn nurseries should preferably be screened after 24 h of life. A screen is taken to be positive, “out of range” or a fail if oxygen saturation is (i) <90%, (ii) <95% in right hand and one foot after three measurements (each taken 1 h apart), or iii) difference of >3% in preductal and postductal saturations after three measurements (each separated by 1 h). POS has a specificity of 99.9% for the detection of CCHDs. It has a false positive rate of 0.05% for the same. It is estimated that POS may be able to detect nearly 50%–70% of infants born with undiagnosed CCHDss. Opportunity and feasibility for POS is higher in the sick nursery even in the resource constrained setting where most of the well nurseries may not have availability of pulse oximeter, echocardiography and neonatal cardiothoracic surgery services. CCHDs can be detected early using POS which is a convenient, noninvasive and cost effective method. All necessary criteria required for inclusion to universal newborn screening panel are fulfilled by POS. The current POS guidelines are for asymptomatic newborns in well newborn nurseries. Evidence based guidelines are still lacking for screening infants in neonatal intensive care settings. We also propose here a protocol for POS in the neonatal Intensive Care Unit.
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Black Pleural Effusion
Surya S Palakuru, Praveen Vijhani, Sujith V Cherian
January-March 2018, 7(1):1-4
Pleural effusions are common in clinical practice. In general, the diagnostic approach starts with thoracentesis. Serous (yellow) and blood tinged (reddish) pleural effusions are the most common types of pleural fluid at thoracentesis. Black colored pleural effusions are an extremely rare entity and knowledge regarding this entity is limited to case reports. A thorough systemic search on PubMed database was done looking at all reported cases of black pleural effusion. Broadly, dividing black pleural effusion based on etiology, the causes are as follows: (1) infectious – especially fungal – Aspergillus niger, Rhizopus oryzae, (2) malignancy -metastatic melanoma and primary lung cancers, (3) pancreaticopleural fistula, and (4) miscellaneous causes-including crack cocaine use, rheumatoid pleurisy, and charcoal containing empyema. Treatment of these effusions involves treatment of the underlying cause. Black pleural effusions are very rare entities with a limited differential, which the treating clinician should consider when encountered in clinical practice.
  208 20 -
Association of left ventricular global longitudinal strain with exercise capacity in heart failure with preserved ejection fraction
Ljubica Georgievska-Ismail, Zarko Hristovski, Planinka Zafirovska
October-December 2017, 6(4):8-13
Background: Left ventricular global longitudinal strain (GLS) analysis using two-dimensional (2D) speckle-tracking echocardiography (STE) is a method for detecting subclinical systolic dysfunction. We hypothesized that exercise capacity (EC) is more closely related to systolic than diastolic dysfunction, especially to GLS in patients with heart failure and preserved ejection fraction (HFpEF). Methods: We assessed LV systolic and diastolic function in 172 patients with HFpEF using 2D echocardiography and STE. EC measured in units of metabolic equivalents (METs) was assessed using Bruce protocol treadmill stress testing. We defined reduced EC as <7 METs. Results: Out of 172 patients, 54 (31.4%) had EC of <7 METs. Patients with reduced EC of <7 METs versus those with ≥7 METs were significantly older (P = 0.0001), female (P = 0.001) with higher body mass index (BMI) (P = 0.001) and waist circumference for both man and women (P = 0.040, P = 0.001, respectively) as well as with higher resting heart rate (HR) (P = 0.009). Logistic regression analysis of EC as the dependent variable revealed that conventional risk factors (age, female gender, higher waist circumference, increased resting HR, and increased diastolic resting blood pressure) appeared as independent predictors of <7 METs. When age, gender, and hypertension were omitted from the analysis the results demonstrated that increased resting HR (odds ratio [OR] 1.025, P = 0.059, 95% confidence interval [CI] 0.997–1.192), higher BMI (OR 1.148, P = 0.003, 95% CI 1.047–1.258) along with elevated E/E' average ratio (OR 1.090, P = 0.059, 95% CI 0.997–1.192) appeared as independent predictors of <7 METs. In addition, when we included only echocardiographic variables into the logistic model, the results showed that only lower GLS% (more positive) appeared as an independent predictor of <7 METs (OR 1.111, P = 0.044, 95% CI 1.003–1.231). Conclusion: Greater impairment of GLS in patients with HFpEF appeared as a significant independent predictor of reduced EC by METs achieved.
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Clinical effects of adding tolvaptan to intravenous furosemide in patients with congestive heart failure
Mahoto Kato, Kazuto Tohyama, Toshiyuki Ohya, Atsushi Hirayama
October-December 2017, 6(4):14-19
Background: Tolvaptan, a vasopressin V2 receptor antagonist, is a strong diuretic with a new mechanism of action and has good adaptation to patients with congestive heart failure. Knowledge on the proper use of furosemide, an existing therapeutic drug, is not yet sufficient. Objectives: Clinical differences when 7.5 mg of tolvaptan was added to the usual furosemide therapy were examined. Materials and Methods: Patients who required hospitalization for congestive heart failure were randomly assigned to a group treated for 7 days with furosemide alone (FRO group) and a group treated with furosemide plus tolvaptan (TLV group) for 7 days and examined for symptoms. Physical examinations were performed every day, and blood testing, including N-terminal pro-brain natriuretic peptide (NT-proBNP) level, plasma renin activity (PRA), plasma aldosterone concentration (PAC), and noradrenaline (NAD) level, was performed on days 1, 3, and 7. Results: FRO and TLV groups consisted of 51 (age, 66.4 ± 11.8 years, 62% of males) and 47 patients (67.9 ± 14.5 years, 64% of males), respectively. During the study, the TLV group had higher urine volume and decreased blood pressure due to the suppressed diuretic effect. The two groups showed significant differences in the degree of improvement of the jugular venous pressure (FRO vs. TLV groups: 6.3 ± 1.6 vs. 7.6 ± 2.5 cmH2O, P < 0.001, on day 3) and other physical findings. Although no significant differences in NT-proBNP and NAD levels were found, there were significant differences in PRA (19.8 ± 12.9 vs. 11.8 ± 8.0 ng/[mL . h], P < 0.001, on day 3) and PAC (FRO vs. TLV groups: 180.4 ± 148.4 vs. 124.7 ± 95.5 ng/mL, P < 0.01 on day 3 and 79.4 ± 73.9 vs. 56.8 ± 38.2 ng/mL, P < 0.05 on day 7). Conclusion: Adding 7.5 mg of tolvaptan to existing treatments with furosemide resulted in differences in clinical findings and neurohormonal factors, even though the degree of improvement in congestive heart failure was the same.
  102 15 -
Effect of cardiac training therapy on minute ventilation/carbon dioxide production slope and exercise parameters in patients with severe chronic heart failure in short-time rehabilitation
Erik C Skobel, Michael Dreher, Christian Knackstedt
October-December 2017, 6(4):20-23
Aim: Treatment for patients with severe chronic heart failure (CHF) (NYHA III, ejection fraction (EF) <30%) consists of medical or cardiac device theraphy, or heart transplantation. Cardiac exercise traning (CET) has also been shown to be effective and safe. Even though exercise therapy improves quality of life and exercise capacity, is not commonly used. The determination of the VE/VCO2slope >34 during exercise have been shown to be useful for mortability risk stratification in CHF. This analysis investigated the effects of 3 weeks' cardiac rehabilitation (CR) on exercise parameters and VE/VCO2 slope in CHF patients. Materials and Methods: Data from 35 patients with CHF (age 68 ± 11 years, 3 female, EF 29 ± 7%, maximum oxygen uptake (VO2max) 10.8 ± 2.7 mL/min/kg, NYHA class III, all ischemic heart disease) on optimal medication who underwent CR including aerobic endurance training theraphy combined with low dose local muscle strength for 3 weeks were evaluated retrospectively using 6 -min walking test, echocardiography and exercise testing. Results: All patients showed improvement in NYHA class, improvement in 6-min walking distance (285 ± 113 m to 431 ± 120 m, P < 0.0001), increasing VO2max (10.8 to 12.9 ± 3.2 mL/kg, P < 0.0001) and reduced VE/VCO2-slope (44.8 ± 9 to 37.1 ± 6, P < 0.0001). These was no significant effect on EF (29 ± 8% to 32 ± 11%). Conclusion: CET for 3 weeks in severe CHF is associated with reduced VE/VCO2-slope and improved exercise capacity. Longer and randomized studies are needed to evaluate the role of VE/VCO2-slope in mortality risk stratification during training in CHF.
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Supraclavicular versus Infraclavicular Subclavian Vein Catheterization in Coronary Artery Bypass Graft Surgery
Masoud Tarbiat, Afshin Farhanchi, Maryam Davoudi, Maryam Farhadian
January-March 2018, 7(1):5-9
Background: Percutaneous central vein catheterization is one of the most invasive procedures commonly performed by anesthesiologists during cardiac surgery. Objectives: The aim of this study was to investigate the complications of supraclavicular (SC) versus infraclavicular (IC) approaches for subclavian vein catheterization during coronary artery bypass graft surgery. Materials and Methods: Between October 2014 and June 2015, this prospective, randomized clinical trial was performed in 280 patients. The patients were randomly cannulated by SC or IC approach. The success and complication rates were compared for the two approaches. The outcome of this study was analyzed using SPSS software and through Chi-square test. Results: In the first attempt of catheterization, the success rate in SC (78.6%) group was lower than IC (94.3%) group (P = 0.0001). The overall success rate in two attempts were 136 (97.1%) in the IC approach and 132 (94.3%) in the SC approach (P = 0.238). In 12 (4.3%) patients, subclavian catheterizations were failed after two attempts in both approaches. In 28 (10%) patients, hematoma at puncture site occurred, 1 (0.7%) in IC approach, and 27 (19.3%) in SC approach (P = 0.0001). The differences in other complications on two approaches were statistically insignificant. Conclusions: Compared with the SC approach, the IC approach resulted in fewer hematomas at puncture sites. The incidence of overall cannulation failure and other complications were similar on both approaches.
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Prevalence of undiagnosed common mental disorders and its association with quality of life among patients attending the arrhythmia clinic of a large tertiary care hospital in Southern India
Gopal Chandra Ghosh, Donae Elizabeth George, Anandaroop Lahiri, Prasanna Samuel, David Chase, John Roshan Jacob
October-December 2017, 6(4):29-33
Objective: Studies are available from high-income countries exploring the prevalence of depression and anxiety among patients with cardiovascular diseases such as coronary artery disease, heart failure, and atrial fibrillation. Similar data are limited from low- and middle-income countries, particularly India. Data on how the quality of life (QOL) parameters are affected by common mental disorders (CMD) such as depression and anxiety are lacking. The aim of this study is to explore the prevalence of undiagnosed depression and anxiety in patients attending the arrhythmia clinic of a tertiary care hospital in Southern India and to look at their association with QOL. Methods: This cross-sectional study involved 282 patients attending the arrhythmia clinic of a tertiary care hospital in Southern India. Depression and anxiety were assessed using the “Patient Health Questionnaire-9” scale and “Hospital Anxiety and Depression Scale for Anxiety” scale, respectively. Patient demographics and potential risk factors were also assessed. Quality of life was assessed using the “Short Form Health Survey” questionnaire. Results: The proportion of patients with undiagnosed CMD (depression or anxiety or both) in our study was 45.74%. This included 32.98% with undiagnosed depression and 32.62% with undiagnosed anxiety. The presence of depression and anxiety are important determinants of quality of life. Presence of hypertension, diabetes mellitus, or smoking is not significantly associated with a poor quality of life in our study. Conclusions: Depression and anxiety are important associations of a poor quality of life. They are commonly seen among those attending the outpatient arrhythmia clinic. Having a screening program for CMD may assist in early diagnosis and intervention in those attending arrhythmia clinics.
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The Effect of Negative Pressure Applied on Chest Tubes in the Amount of Pleural Effusions in Postcoronary Artery Bypass Grafting Patients
Ali Sadeghpour Tabaie, Rasoul Azarfarin, Bahador Baharestani, Shariar Mali, Sepehr Sadeghpour Tabaei
January-March 2018, 7(1):10-14
Background: Application of negative pressure on chest tubes is one of the most common methods for management of chest tubes drainage after cardio-thoracic surgeries. However, the effect of this measure on long-term outcome of these patients and especially on postoperative pleural effusions is not thoroughly evaluated. For this reason, we designed a clinical randomized trial for the evaluation of the effect of negative pressure application on early and late pleural effusions after coronary artery bypass grafting (CABG) operations. Methods: A total of 440 patients entered in this study and divided into two groups: 220 patients, their chest tubes managed by application of −10–−20 cmH2O negative pressure (negative pressure drainage group) and those who managed conventionally by simple under-water seal method (control group, n = 220). Evaluation for pleural effusion performed by signs and symptoms and chest X-rays at 3rd and 7th postoperative days and for those became symptomatic after 30th day of operation. Results: The occurrence of moderate and massive effusions at 3rd and 7th days after operation was the same in both groups. The most striking difference was in patients' required pleural tap or chest tube insertion, late after surgery due to pleural effusion. This was significantly more common in patients in control group (P < 0.001). Conclusion: Negative pressure application on chest tubes after CABG surgery is a safe and effective method for decreasing the occurrence of late pleural effusion.
  70 6 -
Network Mining Indicated the Triglycerides as the Most Related Clinical Relevance to Age-related Transcriptional Changes in the Aorta
Fereshteh Izadi
January-March 2018, 7(1):35-42
Background: Aging is believed to be one of the main causes of cardiovascular diseases. The incidence of cardiovascular dysfunctions has increased substantially over the past few years. However, our understanding of molecular mechanisms of age-related vascular disorders remains somehow unclear, and an effective treatment has not been developed. A biological network is a collection of interactions between molecular regulators and their targets in cells governing gene expression level that is usually built by employing omics data, facilitating the inference of molecular basis of complex diseases. Materials and Methods: GSE50833 series containing aorta samples of 6-month-old mice (n = 6) and 20-month-old mice (n = 6) obtained from Janvier labs (Saint Berthevin, France) were downloaded from Gene Expression Omnibus database and the verified Agilent probe IDs were subjected to build a weighted gene coexpression network by a bioinformatics tool known as Weighted Gene Coexpression Network Analysis. We then conducted a network-driven integrative analysis to find significant modules and underlying pathways. Results: The unique genes extracted from normalized gene expression values were parsed into six modules. Among the incorporated clinical traits, the most significant module was associated with triglycerides enriched in biological terms, including proteolysis, blood circulation, and circulatory system process. Moreover, Enpp5, Fez1, Kif1a, F3, H2-Q7, and Pa × 8 were taken as putative hallmark molecules by further screening. Conclusion: the main goal of this analysis was the prioritization of genes that likely play a role in the pathogenesis of vascular diseases. We attempted to provide a system understanding of the potential connections among these genes.
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Two different methods of determining B-type natriuretic peptide, either from fingertip’s capillary blood or antecubital vein; A comparison regarding diagnostic accuracy in patients with chronic heart failure in NYHA class I-III
Renato De Vecchis, Carmelina Ariano
January-March 2017, 6(1):4-4
Background: In recent years, several systems have been implemented to achieve quick and non-invasive measurements of B-type natriuretic peptide (BNP). Among them, Alere™ heart check (AHC) BNP test represents the most recent advancement. It is a rapid point of care immunoassay (POC), projected for measuring BNP directly from a capillary whole blood sample. Objectives: This study aimed to compare analytical and clinical performances of this new POC to our reference method (Abbott architect system). Patients and Methods: 111 patients with stable chronic heart failure (CHF) referred to two cardiac rehabilitation centers were en- rolled from December 2013 to January 2015. These patients were subjected to a simultaneous capillary (AHC) and plasma (Abbott) BNP measurements. Clinical and analytical performance of AHC were assessed and compared to the reference method. Results: Capillary BNP showed a good correlation with the reference method (r = 0.94, P < 0.0001), although the values diverged when BNP was higher than 1500 pg /mL. Indeed, the AHC had a relatively poor precision and the coefficient of variability was 10.1% and 18% for low and high controls, respectively. However, both methods showed similar diagnostic performances in discriminating patients with heart failure in NYHA class I from those belonging to NYHA classes II-III, with values of area under the curve (AUC) of 0.983 and 0.984, respectively, and equivalent sensitivity, specificity and positive and negative likelihood ratios. Conclusions: The AHC BNP test is a good POC able to provide reliable information about hemodynamic status of CHF patients, especially of those belonging to NYHA classes I-III.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub]
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Effect of exercise on left ventricular mass index by echocardiography in mild and moderate hypertension: A meta-analysis
Mohamed Teleb, Aaron Shanker, Alok Kumar Dwivedi, Debabrata Mukherjee
October-December 2017, 6(4):50-56
Background: Left ventricular (LV) hypertrophy is considered to be a significant manifestation of increased blood pressure, which is associated with an increased risk of cardiovascular morbidity and mortality. Exercise training is recommended for reducing blood pressure in mild and moderate hypertensive patients. Methods: We conducted a search for interventional studies evaluating the effect of exercise on LV mass index (LVMI) in hypertensive patients. Studies were searched using different databases from 1990 to 2015. The primary end points were change in LVMI, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Of 122 studies, eight studies were found to be eligible for this meta-analysis. Results: The produced effect size was found to be large for LVMI (3.6, 95% confidence interval [CI]: 1.7–5.5) and DBP (2.8, 95% CI: 1.6–3.9) with significant heterogeneity, while moderate (0.56, 95% CI: 0.35–0.77) for SBP without significant heterogeneity. The estimated predictive intervals for LVMI (95% CI: −3.2–10.3) and DBP (95% CI: −1.3–6.8) showed a positive but not significant difference in the intervention and control groups. Conclusion: The study demonstrated a significant reduction in LVMI and DBP in hypertensive patients after exercise training. A moderate reduction in the SBP of these patients was also depicted after exercise. Our study supports the American College of Cardiology/American Heart Association guidelines for regular exercise in hypertension.
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Nutritional status assessment of the elderly patients with congestive heart failure by mini nutritional assessment test
Shirin Hosseini, Seyed Ali Keshavarz, Ahmad Amin, Hooman Bakshandeh, Majid Maleki, Alireza Shahinfard, Shadi Hosseini, Mona Heidarali
January-March 2017, 6(1):1-1
Background: Malnutrition is a common problem among elderly patients, especially those with heart failure, and is known to increase mortality rates. Objectives: The current study evaluated nutritional status to identify changes in the elderly patients with congestive heart failure (CHF) during hospital stay. Patients and Methods: This cross-sectional study recruited 225 CHF hospitalized elderly patients, comprised of 154 males (68.4%) and 71 females (31.6%) at ameanage of 71.1±7.35 years. The mini nutritional assessment (MNA) was performed to estimate functional, cognitive and nutritional status. The MNA, an18-item tool to evaluate subjective and objective findings, including anthropometric measurements for nutritional risk, is found to be sensitive, specific and accurate in identifying elderly people at nutritional risk. Results: According to the MNA questionnaire, 9.8% of the elderly were malnourished, 80.9% at risk of malnutrition and 9.3% well nourished.Weight loss, bedsore, and level of knowledge and income had a significant relationship with nutritional status based on the MNA (P value < 0.05). Conclusions: Considering the high percentage of elderly patients with malnutrition or at risk of malnutrition, the need for nutritional intervention is obvious. The MNA seems to be a reliable tool to identify individuals at risk of malnutrition. To decrease hospital stay duration and cost, application of the MNA is suggested.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]
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Comparison of Enoxaparin versus Heparin among Patients Undergoing Elective Coronary Angiography via Radial Artery Access
Reza Kiani, Mohammad Javad Alemzadeh-Ansari, Vahid Feghhi, Ata Firouzi, Hamid Reza Sanati, Ali Zahedmehr, Farshad Shakerian, Ahmad Shakeri, Reza Beheshti Namdar, Mohammad Reza Baay, Amir Mikailvand, Sayyed Shahrokh Taghavi
January-March 2018, 7(1):15-19
Background: Radial artery occlusion (RAO) is one of the few postprocedural complications of transradial approach (TRA) which may be symptomatic in some cases. The aim of this study was to investigate the safety and efficacy of enoxaparin compared with unfractionated heparin (UFH) for preventing RAO among patients who underwent elective diagnostic coronary artery angiography (CAG) via TRA. Patients and Methods: This randomized clinical trial study was conducted on patients who underwent TRA for elective diagnostic CAG. Then, the patients included were randomly divided into 2 groups. A group received 0.75 mg enoxaparin intravenously and the second group received 70–100 IU/Kg UFH single-bolus dose intravenously. During 24 h after the procedure and 3 months later, all the participants were monitored for the occurrence of RAO, access hematoma, periprocedural myocardial infarction, stroke, and death. Results: From 189 patients with mean age of 52.52 ± 6.23 years old, 95 patients received UFH (70–100 IU/kg), and the other group (n = 94) received enoxaparin after radial sheath insertion. After 24 h, decrease in radial pulse was observed in 17.6% patient (14.9% in UFH group and 20.2% in enoxaparin group) and only one patient had absent radial pulse in UFH group. There were no significant differences between UFH group compared with enoxaparin group in the reduction of the radial pulse that examined with reverse Allen test (P = 0.359). Furthermore, other complications did not differ significantly between the two groups. Conclusion: This study demonstrates that intravenous enoxaparin administration compared with intravenous UFH during diagnostic CAG via TRA is a safe and effective strategy for preventing RAO at 24 h after the procedure.
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Effect of various patient positions on endotracheal tube cuff pressure after adult cardiac surgery
Mohsen Ziyaeifard, Rasoul Ferasatkish, Azin Alizadehasl, Zahra Faritous, Seyed Mostafa Alavi, Hamidreza Pouraliakbar, Maryam Zare, Ehsan Dehdashtian
October-December 2017, 6(4):34-37
Background: To avoid microaspiration or tracheal injury, the target endotracheal tube cuff pressure must be maintained 20–30 cmH2O. Changing in patients' positions may effect on endotracheal tube cuff pressure. The aim of this study was to investigate the effect of various patients' positions on endotracheal tube cuff pressure after adult cardiac surgery. Methods: This prospective, interventional study was conducted on 25 adult patients with orotracheal intubation for the cardiac surgery. Patients' endotracheal tube cuff pressure was assessed after surgery in a neutral starting position during an end-expiratory hold, and cuff pressure was regulated at 25 cmH2O. Then, ten changes in head position were performed: anteflexion, hyperextension, left and right lateral flexion, left and right rotation, semi-recumbent position (head elevation in 45°), recumbent position (head elevation in 10°), horizontal supine position, and finally, Trendelenburg position (10°). The observed cuff pressures were compared with the basic cuff pressure at the starting position. Results: Of total 250 measurements (25 participants in 10 positions), 109 (43/6%) were greater than the upper target limit of 30 cmH2O. In contrast, no measurements were less than the lower target limit of 20 cmH2O. 141 (56/4%) measurements were between the target limit of 20–30 cmH2O. All ten changes of patients' head position lead to statistically significant increase in endotracheal tube cuff pressure (P < 0.05). Conclusion: Simple changes in intubated patients' position could significantly increase in endotracheal tube cuff pressure that may potentially damage tracheal mucosa.
  52 13 -
Changes in exercise capacity and psychosocial factors in hospitalized cardiac surgery patients
Masato Ogawa, Kazuhiro P Izawa, Aki Kitamura, Seimi Satomi-Kobayashi, Yasunori Tsuboi, Kodai Komaki, Yoshitada Sakai, Hiroshi Tanaka, Yutaka Okita
October-December 2017, 6(4):38-44
Background: After cardiac valve surgery, postoperative exercise capacity and psychosocial parameters of patients change significantly and both affect prognosis. This study aimed to analyze and clarify the relationship between changes in perioperative exercise capacity and psychosocial factors in the early phase after valvular surgery. Materials and Methods: We enrolled 48 consecutive patients who underwent valvular surgery and studied their exercise capacity, health-related quality of life (HRQOL), anxiety disorders, depression symptoms, blood samples, and echocardiograms preoperatively and 14-day postoperatively. Results: At the preoperative evaluation, the peak maximal oxygen consumption was 17.7 ± 5.9 ml/kg/min and decreased by 14.3 ± 4.4 ml/kg/min after the surgery (P < 0.0001). With regard to the HRQOL, the physical component summary (PCS) score and the role component summary scores decreased significantly after surgery (P < 0.05 for each). However, the mental component summary score increased significantly after surgery (51.9 ± 11.6 to 55.2 ± 10.4; P = 0.04). The ratios of the above the cut-off value for postoperative anxiety and depression scores were 29.1%, and 43.7%, respectively. Postoperative changes in exercise capacity were associated with variations in right ventricular function, chronotropic response during exercise, and the PCS score (P < 0.05 for each). Conclusions: Exercise capacity was reduced approximately 20% during the postoperative period in patients who underwent valvular surgery, and changes in exercise capacity were related to changes in psychosocial factors, not only cardiac functions. Therefore, it is important to evaluate not only perioperative exercise capacity but also psychosocial indicators during postoperative cardiac rehabilitation programs.
  52 12 -
The Effect of Intracoronary Infusion of Bone Marrow-derived Mononuclear Cells on Clinical Outcome and Cardiac Function in Chronic Heart Failure Patients: An Uncontrolled Study
Ahmad Amin, Ata Firouzi, Arezoo Mohamadifar, Nasim Naderi, Behshid Ghadrdoost, Hoda Madani, Nasser Aghdami
January-March 2018, 7(1):26-30
Objective: To evaluate the effect of bone marrow-derived mononuclear cells (BM-MNCs) on clinical outcome and cardiac function in chronic heart failure (HF). Methods: An uncontrolled, open-label trial was performed on symptomatic patients (New York Heart Association [NYHA] Functional Classification II–IV) receiving maximal medical therapy for at least 2 months, with a left ventricular (LV) ejection fraction <25%. Patients were divided into ischemic and nonischemic subgroups. All patients underwent BM aspiration, isolation of BM-MNCs using a standardized system, and intracoronary infusion of BM-MNCs. Primary endpoints assessed in 36 months were changes in (1) LV systolic function and LV end-diastolic diameter by echocardiography and (2) clinical improvement. Secondary measures included other echocardiography measures and major adverse cardiac events and HF hospitalization. Phenotypic and functional analyses of the cell product were performed by the Royan Institute for stem Cell Biology and Technology laboratory. Results: We enrolled 58 patients in our study. There was a significant improvement to exercise and functional capacity (evaluated by NYHA classification and 6-min walking distance) with both groups (for all P < 0.001). A significant decline in serum N-terminal Prohormone of Brain Natriuretic Peptide(NT- ProBNP) was observed in ischemic group (P = 0.01), but it was not statistically significant in nonischemic group. No significant changes were found in LV systolic and diastolic function, right ventricular size and function, severity of Mitral and Tricuspid regurgitation and pulmonary arterial pressure. There was minimal decrease in LV end-diastolic diameter which was statistically significant in ischemic and nonischemic group (P = 0.008 and P = 0.01 accordingly). Our study revealed a remarkably safe profile for BM-MNC infusion. Conclusion: It seems that intracoronary infusion of bone marrow-derived mononuclear stem cells is a safe treatment for patients with advanced HF and further studies need to address the best type of cell, route of administration, and criteria for patient selection.
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Hostility, anger, and cardiovascular mortality among blacks and whites
Shervin Assari
January-March 2017, 6(1):2-2
Background: Despite the well-known impact of baseline hostility and anger on subsequent cardiovascular mortality, few studies have tested whether predictive role of hostility and anger on mortality varies as a function of race and gender. Objectives: Current study explored role of race and gender in modifying the effects of baseline hostility and anger on cardiovascular mortality in a nationally representative sample in U.S. Materials and Methods: We used data from the Americans’ changing lives study, a nationally representative longitudinal cohort of U.S. adults. The study followed 1,593 Blacks or Whites for 10 years from 2001 to 2011. Independent variables were baseline hostility and anger (anger-in, and anger-out), measured at 2001, using 4 item Cook-Medley cynical hostility scale and Spielberger Anger Expres- sion scales, respectively. Dependent variable was time to death due to cardiovascular disease since 2001. Covariates were baseline socio-demographics (age and education), behaviors (smoking and drinking), and health (number of chronic medical conditions, self-rated health, and depressive symptoms) measured at 2001. We used Cox proportional hazard models in the pooled sample and specific to race, in the absence and presence of health variables. Results: In the pooled sample, baseline hostility and anger-out predicted cardiovascular mortality in the next 10 years. We found significant interactions between race and baseline hostility and anger-in on cardiovascular mortality, suggesting that these associ- ations are stronger for Whites than Blacks. Race did not interact with baseline anger-out on cardiovascular mortality. Gender also did not have any interactions with baseline hostility, anger-in, or anger-out on cardiovascular mortality. Conclusions: Hostility and anger-in better predict cardiovascular mortality among Blacks than Whites in the United States. Black - White difference in the associations of hostility and anger with cardiovascular mortality suggest these factors may have some role in shaping health disparities across racial groups.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub] [CITATIONS]
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Effect of dexmedetomidine infusion on hemodynamics and stress responses in pediatric cardiac surgery: A randomized trial
Ziae Totonchi, Hengameh Rezvani, Masoud Ghorbanloo, Forouzan Yazdanian, Mohammad Mahdavi, Nima Babaali, Shirin Salajegheh, Mitra Chitsazan
January-March 2017, 6(1):7-7
Background: Infants and children compared with adults have intensified stress responses that lead to increased morbidity and mortality. Stress control reduces the incidence of complications and improves recovery. In clinical and experimental studies, dexmedetomidine reduces the inflammatory and neuroendocrine responses. Objectives: This prospective randomized double-blinded clinical trial was conducted to assess the role of dexmedetomidine in reducing stress responses. Materials and Methods: According to convenient sampling method, 40 patients in two groups (case under treatment with dexmedetomidine and control, each including 20 patients) were selected from whom admitted for open heart surgery. Anesthe- sia was induced and maintained by fentanyl and midazolam. After central venous and arterial catheter insertion, patients were randomly allocated into one of two equal groups (n = 20 each). In the dexmedetomidine group, patients received an initial loading dose (0.5 μg/kg) during10 minutes immediately followed by a continuous infusion of 0.5 μg/kg. In the control group, normal saline solution with similar volume was infused. Results: Changes in heart rate, systolic and diastolic blood pressures and central venous pressure before administration of dexmedetomidine, in 10, 20 and 30 minutes after the operation, after skin incision, after sternotomy, after separation from the pump and at the end of procedure showed no significant difference between the two groups (P = 0.860, 0.067, 0.888 and 0.482, respectively). Changes in lactate, interleukin 6, tumor necrosis factor, C-reactive protein concentrations before administration of dexmedetomidine, after separation of pump and 24 hours after intensive care unit entrance showed no significant difference be- tween the two groups (P = 0.525, 0.767, 0.868 and 0.840, respectively). Conclusions: According to our findings, using dexmedetomidine as an adjuvant anesthetic medication with initial loading dose of 0.5 μg/kgand maintenance dose of 0.5 μg /kg in pediatric heart surgeries is a safe choice. However, further studies are needed to clarify the role of dexmedetomidine to reduce stress responses.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub]
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Cardiac surgery with crystalloid cardioplegia: Improved functional recovery due to molecular adaptations in adult rat hearts
Andreas Boening, Tim Attmann, Martina Heep, Bernd Niemann, Philippe Grieshaber, Rolf Schreckenberg, Klaus-Dieter Schlueter
October-December 2017, 6(4):45-49
Background: The effect of aging on functional recovery after a period of crystalloid cardioplegic arrest is still a matter of debate. We hypothesized that age-dependent differences in the polyamine metabolism may contribute to such differences. Methods: Hearts from juvenile and adult Wistar rats were placed in a perfused beating heart model and given Bretschneider's cardioplegia for an ischemia period of 60 min. During reperfusion, recovery of contractile function and coronary blood flow were measured for 90 min. In addition, adult hearts received putrescine to bypass polyamine metabolism during the 1st min of reperfusion. In comparison, the effect of putrescine was analyzed from hearts reperfused after 45-min flow arrest for 90 min. The rate-limiting enzyme of the polyamine metabolism, ornithine decarboxylase (ODC), the proapoptotic enzyme bax, and the relation between SR-calcium-ATPase (SERCA2a) and a natrium-calcium-exchanger enzyme were determined on mRNA-level through real-time polymerase chain reaction. Results: Adult hearts had lower basal performance and lower SERCA mRNA expression compared to juvenile hearts. However, after a 60-min aortic clamping period, recovery of left ventricular developed pressure (105.6 ± 39.7% of baseline) in the adult group was better than in the young group (61.3 ± 34.1% of baseline). ODC mRNA was significantly (P = 0.04228) lower in adult hearts (0.60 ± 0.09-fold vs. juvenile rats). Similar, bax mRNA was significantly (P = 0.01662) lower in adult hearts (0.22 ± 0.03-fold vs. juvenile rats). Addition of putrescine to adult hearts during reperfusion attenuated a better outcome of these hearts suggesting a detrimental effect of polyamine metabolism after cardioplegic arrest. In contrast, putrescine improved recovery in postischemic hearts without exposure to cardioplegic solution. Conclusion: Adult rat hearts tolerate cardioplegia-mitigated ischemia better than juvenile hearts because they express less ODC during resubstitution of normal calcium levels.
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Nutritional assessment of elderly cardiovascular patients
Vitorino Modesto dos Santos
October-December 2017, 6(4):60-61
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Two undesired conditions resulting from T-Wave oversensing in two patients with hypertrophic cardiomyopathy: Inappropriate ICD shocks and pacemaker dysfunction
Filiz Kizilirmak, Gultekin Gunhan Demir, Oguz Karaca, Umeyir Savur, Fethi Kilicaslan
January-March 2017, 6(1):11-11
Introduction: T-wave oversensing (TWOS) is generally seen in patients with hypertrophic cardiomyopathy (HCM) and is a rare cause of inappropriate implantable cardioverter defibrillator (ICD) shocks. TWOS rarely causes pacemaker dysfunction. Case Presentation: In this paper, we present two patients with hypertrophic cardiomyopathy (HCM). One patient had several in- appropriate ICD shocks, and the other experienced pacemaker dysfunction due to TWOS. ICD interrogation revealed that TWOS occurred only during high heart rates in the first patient. Attempts to fix TWOS, including a higher beta blocker dose, electrophysi- ology study, and ICD re-programming, were unsuccessful. Conclusions: We replaced the previously implanted ICD generator (Medtronic Maximo II DR) with a new one that has a specific diagnostic algorithm to prevent TWOS (Medtronic Protector). After replacement, the patient did not have any inappropriate shocks due to TWOS. The second patient had bradycardic pacemaker rhythm due to TWOS. Although we reposed, the ventricular lead did not stabilize with an adequate threshold, and thus we decided to replace the lead with a new one. The pacemaker dysfunction disappeared after the lead replacement. Patients with HCM must be observed carefully for these undesired conditions.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub]
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Ruptured left ventricular pseudoaneurysm: A complication of power injector assisted ventricular angiography
Amer Hawatmeh, Ahmad Abu Arqoub, Ashraf Jmeian, Ahmad Isbitan, Fayez Shamoon
January-March 2017, 6(1):12-12
Introduction: Left ventricular pseudoaneurysm; also referred to as contained left ventricular wall rupture, is a rare complication that is reported in about 0.2 to 0.3 percent of all myocardial infarction patients. Since it has a high risk of fatal rupture, early surgical repair is recommended once pseudoaneurysm is diagnosed. Case Presentation: In this case report, we are describing a case of a left ventricular inferior wall pseudoaneurysm which was diag- nosed by angiography, and was complicated by rupture and cardiac tamponade shortly after the patient received a powered assisted left ventricular angiogram. Conclusions: This case exemplifies that pseudoaneurysm represents a part of the ongoing process of ventricular rupture, that begins with a small tear in the endocardium and then extends to the myocardium and the pericardial cavity, causing hemoperi- cardium and cardiac tamponade. Therefore, earlier recognition and urgent surgical repair can be lifesaving.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub]
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Coronary-subclavian steal syndrome following CABG: A case report and literature review
Alireza Rostami, Mehrzad Sharifi, Yazdan Ghandi
January-March 2017, 6(1):10-10
Introduction: Coronary-subclavian steal syndrome (CSSS) is not a common complication but it can cause recurrent angina following coronary artery bypass grafting(CABG). CSSS results from proximal subclavian artery stenosis causing reversal of blood flow in apatent in situ internal thoracic artery utilized as a conduit in CABG, leading to myocardial ischemia. Case Presentation: We present a case of CSSS successfully treated with carotid-subclavian bypass (CSB). A review of articles on the subject has also been conducted. Conclusions: Although CSSS is not a common condition, it should be strongly considered as a possibility in CABG patients presenting with recur- rent chest pain not to be confused with perioperative myocardial infarction (PMI). If indicated, carotid-subclavian bypass maybe performed as an effective treatment option with acceptable outcomes.
[ABSTRACT]   Full text not available  [PDF]  [Mobile Full text]  [EPub]
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Prevalence of left atrial diverticula and accessory appendages and origins of the sinoatrial nodal artery in patients with atrial fibrillation
Hamidreza Pooraliakbar, Fatemeh Babaei, Majid Haghjoo
July-September 2017, 6(3):1-1
Background: Considering the importance of knowledge about anatomical variations in the left atrium (LA) and its nearby structures for clinical decision-making and the lack of pertinent studies on Iranian patients, this study was conducted to determine the prevalence of LA diverticula and accessory appendages and the origins of the sinoatrial (SA) nodal artery in patients with atrial fibrillation. Methods: In this observational cross-sectional study, 45 consecutive patients with atrial fibrillation undergoing preprocedural computed tomography angiography were enrolled. The prevalence rates of LA diverticula and accessory appendages and the origins of the SA nodal artery were determined and compared according to the patients' age and gender. Results: The origin of the SA nodal artery was R1 (medial to right auricle) in 30 patients (66.7%), L1 (medial to left auricle) in 11 patients (24.4%), and both R1 and L1 in 1 patient. The origin in the remaining 3 subjects was L2 (posterior to auricle), L3 (posterior to left atrium), and R2 (posterior to right atrium). The prevalence rates of LA diverticula and accessory appendages were 48.9% and 17.8%, respectively. Diverticula were seen in 34.8% and 63.6% of the patients younger and older than 50 years, respectively (P = 0.050). Also, accessory appendages were present in 30.4% and 4.5% of the patients younger and older than 50 years, respectively (P = 0.047). There was no significant association for age (P > 0.05). Conclusions: The findings of the present study show that the main supplying artery of the SA nodal artery was R1 from the right coronary artery. The prevalence rates of LA diverticula and accessory appendages were higher than those reported previously.
[ABSTRACT]   Full text not available  [PDF]
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