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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.
  199 553 -
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.
  549 68 -
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.
  486 43 -
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.
  382 58 -
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.
  350 52 -
Acute Complications in Cardiac Electrophysiology Procedures: A Prospective Study in a High-volume Tertiary Heart Center
Ali Vasheghani-Farahani, Akbar Shafiee, Mohammadali Akbarzadeh, Negar Bahrololoumi-Bafruee, Abolfath Alizadeh-Diz, Zahra Emkanjoo, Amirfarjam Fazelifar, Hooman Bakhshandeh, Majid Haghjoo
January-March 2018, 7(1):20-25
Background: Several complications can occur during electrophysiology (EP) study and radiofrequency catheter ablation (RFCA). In this study, we aimed to determine the frequency and types of complications following EP study and RF ablation in a tertiary cardiovascular center. Methods: Between September 2012 and December 2012, patients undergoing RF ablation and EP studies were prospectively enrolled. Demographic and clinical data of the patients, as well as the underlying arrhythmia and indication for EP study, were recorded. Complications occurring during the procedure and admission period were documented. Results: A total of 382 procedures were performed in 357 patients with the mean age of 47 ± 18 years within the study period. The most common arrhythmia was atrioventricular nodal reentrant tachycardia (26.4%). Major complication happened in 10 (2.6%) procedures while minor complications occurred in 36 (9.4%) procedures. Tamponade was the most common major complication (n = 3 [0.7%]), and pericardial effusion was the most common minor complication (n = 19 [4.9%]). Patients with complication were significantly younger and had a lower ejection fraction (P = 0.003 and P = 0.02, respectively). Conclusion: The complications observed in this study are comparable to previous reports, and EP study and RFCA can be considered as safe procedures.
  307 48 -
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.
  291 36 -
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.
  277 47 -
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.
  255 32 -
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.
  228 43 -
Does opium have benefit for coronary artery disease? A systematic review
Tolou Hasandokht, Arsalan Salari, Soheil Soltani Pour, Heidar Dadkhah Tirani, Bijan Shad, Elyas Rajabi
April-June 2018, 7(2):51-58
Opium is a plant with euphoria effect. People from some parts of the world traditionally use opium for cardioprotective effects. We did a systematic review to assess the effect of opium on coronary artery disease (CAD). A systematic database search was conducted in PubMed, Web of Science, Google Scholar, Cochrane library, Scopus, and SID from their onset up to June 2016. The quality of the studies was assessed with a standardized scoring system. Articles assessing the effect of opium consumption as orally or smoked were included in this review. Outcome was defined as age on CAD disease, risk of CAD, and morbidity from CAD. Poor methodological studies, animal studies, and studies on cardiovascular risk factors or serum markers were excluded from the review. Three case–control, three cohort, and eight cross-sectional studies were included in this systematic review. The age at the occurrence of myocardial infarction, coronary bypass surgery, and percutaneous intervention in opium users was signifi cantly lower than that of nonusers. Odds ratio of opium consumption for CAD ranged from 1.3 to 3.8 in different studies. Hazard ratio of opium consumption for ischemic heart disease was 1.90 (1.57–2.29) with modification by sex, ethnicity, education level, marital status, residential place, and cigarette smoking. We concluded, in spite of the traditional belief, that the current evidence did not support the protective effect of opium on CAD. Future well-designed studies concerning probable confounders in Iran and other similar parts of world are required.
  207 52 -
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.
  223 26 -
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.
  214 30 -
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.
  206 36 -
The Results of a 2-year Experience in Pediatric Heart Transplant in Rajaie Cardiovascular Medical and Research Center
Mohammad Mahdavi, Golnar Morataz Hejri, Hooman Bakhshandeh, Ahmad Amin, Ali Sadeghpour Tabaei, Maziar Gholampour Dehaki, Saeid Hosseini, Zeai Totonchi, Bahador Baharestani
January-March 2018, 7(1):31-34
Introduction: Heart transplantation is the ultimate treatment method for many infants and children with the diagnosis of cardiomyopathy or final stages of congenital heart failure. Purpose: This report provides the results of children's heart transplantation in Shahid Rajaie Heart Center during a 2-year period. Methods: Studying retrospective information of heart-transplanted children between 2012 and 2015. Results: Nineteen cases of pediatric heart transplantation were performed between 2012 and 2015 on children aged between 16 months and 14 years with an average age of 10 months. Among these, 14 (73.7%) cases were male and 5 (26.3%) cases were female. Among heart-transplanted cases, 10 (52.6%) cases were diagnosed with idiopathic dilated cardiomyopathy, 1 (5.3%) case was diagnosed with myocarditis, 7 (36.8%) cases were diagnosed with left ventricular (LV) noncompaction, and 1 (5.3%) case was diagnosed with myocarditis and LV noncompaction. After the heart transplantation, two cases suffered from pericardial effusion, three cases suffered from renal failure, three cases suffered from the right heart failure, three cases received extracorporeal membrane oxygenation, one case suffered from hypersensitivity to mycophenolate mofetil, and one case suffered from polyradiculopathy. Conclusion: Our short-term experience shows good results with low mortality rates and controlled complications of heart transplantation. Although we are in the early stages and are going through experiences, we expect to get better results given that there is an increase in the number of donors alongside improvements in immunosuppressive treatments and appropriate antibiotics.
  181 43 1
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.
  195 28 -
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.
  180 18 -
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.
  168 25 -
Ventricular Arrhythmia and Left Ventricular Dysfunction: A Rare Manifestation of Adrenal Adenoma
Mohammad Javad Alemzadeh-Ansari, Zahra Emkanjoo, Bahram Mohebbi, Hamid Reza Pouraliakbar
January-March 2018, 7(1):46-48
Primary aldosteronism is characterized by hypertension, suppressed plasma renin activity, increased aldosterone excretion, and hypokalemia with metabolic alkalosis. Ventricular arrhythmia is an uncommon finding. We report the case of a 46-year-old female who was referred to our center due to uncontrolled ventricular arrhythmia. The past medical history was positive for hypertension. On admission, echocardiography showed severe left ventricular (LV) dysfunction. Blood examination revealed severe hypokalemia. She had been diagnosed with acute coronary syndrome and decompensated heart failure elsewhere and was given diuretics. A diagnosis of primary aldosteronism due to adrenal adenoma was made according to laboratory findings and imaging modalities. The prompt management of bradycardia and correction of hypokalemia, along with surgical resection of adrenal adenoma, resulted in control of arrhythmias and improvement in LV function.
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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.
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Study of prooxidant-antioxidant balance and some risk factors of coronary artery disease
Farzaneh Montazerifar, Mansour Karajibani, Sara Musavi Gilani, Ahmad Bolouri, Mohammad Hashemi, Alireza Dashipour
April-June 2018, 7(2):69-73
Background: There is evidence that oxidative stress can be considered as a critical event in the development of atherosclerotic complications. In this study, we aimed to assay the values of prooxidant-antioxidant balance (PAB) in patients with coronary artery disease (CAD), as a cardiovascular risk factor, and its relationship with some clinical, biochemical, and anthropometric parameters was examined. Materials and Methods: In a case–control study, forty CAD patients and forty age and body mass index (BMI)-matched healthy controls hospitalized in the cardiology section of Imam Ali hospital of Zahedan, Iran, were enrolled. The levels of serum lipid profile, C-reactive protein (CRP), blood pressure, BMI, and waist circumference (WC) were evaluated. The values of PAB were also assayed simultaneously by photometric method, using 3, 3′, 5, 5′-tetramethylbenzidine and its cation, used as an indicator of redox. Results: PAB was found to be significantly higher in CAD patients (P < 0.05) as compared with control group. The obese patients had higher values than nonobese patients and controls (P < 0.05). In CAD patients, a significant positive correlation was demonstrated between WC (r = 0.56, P = 0.05), high-sensitivity-CRP (r = 0.65, P = 0.04), cholesterol (r = 0.36, P = 0.052), and triglyceride (r = 0.29, P = 0.055) with PAB. Conclusion: The study shows that the PAB assay in conjunction with other risk factors can be used as an independent prognostic predictor of CAD, particularly in patients who need antioxidant therapy.
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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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Hemodynamic parameters to predict time to clinical worsening in end-stage heart failure
Ahmad Amin, Arezoo Mohamadifar, Nasim Naderi, Sepideh Taghavi, Behshid Ghadrdoost
April-June 2018, 7(2):74-77
Background: Along with advances in end-stage heart failure (HF) treatments, such as heart transplantation (HTx) and ventricular assist devices as destination therapy, there is an increasing need to define scoring systems for selecting the most suitable candidates for these interventions. Furthermore, constraints in donor number necessitate the precise evaluation of patients before candidacy for HTx. Methods: We enrolled eighty patients with severe symptomatic HF, left ventricular ejection fraction <30%, and New York Heart Association Functional Class III–IV. All patients underwent right heart catheterization for hemodynamic assessment and were followed for 18 months. We defined cSVO2 as the ratio of right atrial pressure (RAP) to mixed venous saturation. Results: During follow-up, 13 patients died, 7 patients underwent HTx, and 36 patients were hospitalized with signs and symptoms of HF. Among hemodynamic parameters, RAP and cSVO2had strongest association with prognosis and clinical worsening. Conclusion: Defining predictors of clinical worsening has great importance in HF. The current study showed cSVO2as a strong predictor of clinical worsening in end-stage HF.
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Tadalafil and exercise capacity after fontan operation
Zahra Khajali, Mohammad Mehdi Peighambari, Sara Lotfian, Maryam Golari, Bahar Galeshi, Morteza Rouhani, Zahra Alizadeh
April-June 2018, 7(2):64-68
Background: Patients with congenital heart defects that have single functional ventricle undergo Fontan surgery. After the surgery, patients will develop reduced capacity for physical activity and exercise. Phosphodiesterase inhibitor drugs have vasodilatory effects and can decrease blood flow resistance. Thereby, they can help to improve the exercise capacity of patients. The aim of this study was to assess the effect of tadalafil on exercise capacity in these patients. Materials and Methods: In this before and after interventional study, 16 patients who had undergone Fontan operation were treated with tadalafil (10 mg daily for 2 weeks and then 10 mg every 12 h for 6 months). Demographic data, heart disease morphology, pulse oximetry, blood pressure (BP), functional class, age at the time of surgery, and the surgery type were collected. Pulmonary function and exercise capacity were assessed by 6-min walk test and VO2 max (maximal oxygen consumption). Results: Mean distance based on 6-min walk test increased from 418.75 m to 439.06 m (P = 0.004). Mean maximal oxygen consumption increased from 0.84 L/min to 1.07 L/min (P < 0.001). Furthermore, preexercise test oxygen saturation increased from 89% to 90.94% (P = 0.02). No significant change was observed regarding other variables. Conclusion: Tadalafil was found to be effective in improving exercise capacity of the patients with a previous history of Fontan surgery. However, tadalafil had no significant effect on systolic or diastolic BP and heart rate.
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Prosthesis-Patient mismatch after aortic valve replacement: A single-center experience
Sedigheh Saedi, Majid Maleki, Behshid Ghadrdoost, Fatemeh Karamali
April-June 2018, 7(2):59-63
Background: The impact of prosthesis-patient mismatch (PPM) on early and late outcomes after aortic valve replacement (AVR) remains controversial. In this study, we aimed to investigate the patient and surgery-related factors leading to various severities of PPM following AVR. Methods: Ninety-six patients who had undergone AVR with a prosthetic valve between 2001 and 2013 and later found to have PPM were enrolled. PPM was defined as the indexed effective orifice area (iEOA) of the aortic prosthesis to be ≤0.8 cm2/m2. PPM was considered to be of moderate or severe degrees if the iEOA was between 0.66 and 0.85 cm2/m2 or ≤0.65 cm2/m2, respectively. Results: The mean age of patients was 26 ± 15 years, and 51% of patients were female. Sixteen patients (15.2%) had mild PPM, 40 patients (38.1%) had moderate PPM, and 40 patients (38.1%) had severe PPM. The majority of our patients had surgery due to congenital causes. Prosthetic valve size and preoperative left ventricular outflow tract diameter were factors statistically related to PPM in the three groups (P < 0.05). There was only one death that was in severe PPM group due to severe heart failure. Conclusion: PPM is a substantial yet underrated clinical entity in patients undergoing prosthetic valve replacement surgery. Patients with smaller body surface areas, surgery at earlier age, and underlying congenital heart disease are more commonly prone to the development of PPM. As our center is referral for the patients affected with congenital aortic valve disease, mindful scheduling and performance of the aortic valve replacement surgery in this patient population is highly recommended.
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