Search

Objective and Background: During the past decade, many researchers have indicated that open cardiac surgery, using cardiopulmonary bypass, could be an essential factor to induce post-operative electrolyte imbalances which may be followed by life threatening complications such as arrhythmia. Nevertheless, by this time there may be a few researches about comparing of hypomagnesaemia and other electrolyte imbalances between open, on pump, and closed, off pump, heart operation., Methods: In this cohort study conducted at Rajaie Heart Center in Tehran from December 2014 to August 2015, we evaluated hypomagnesaemia, hypocalcemia, hypokalemia and hyponatremia in 205 children aged under 15 years who underwent open (101 children) and closed (104 children) cardiac surgery. Repeated measures ANOVA, paired t test and Chi-square/Fisher exact test were used for analysis the data in SPSS version 21., Results: According to our study the frequency of electrolyte imbalances including hypomagnesaemia after pediatric heart surgery is relatively high (28.7% hypomagnesaemia at the second day) with more occurrence in closed cardiac operations. There was no significant relationship between hypomagnesaemia and pump time duration (P>0.05). On the other hand, this research indicated that there is significant relationship between post-operative hypomagnesaemia and some other variables including cyanotic heart disease (P=0.01) and concurrent electrolyte imbalance such as hypocalcaemia and hypokalemia (P<0.05)., Conclusion: Early evaluation and correction of hypomagnesaemia should be considered after both closed and open heart operation., Competing Interests: Conflict of Interest: None declared.

Blood priming is needed for cardiopulmonary bypass (CPB) in neonates and infants to avoid exceeding hemodilution; however, transfusion-related inflammation affects post-CPB outcomes in infant open-heart surgery. Procalcitonin, a newly detected inflammatory moderator and a sensitive parameter for predicting pulmonary dysfunction secondary to CPB, rises after CPB. We hypothesized that the hemofiltration of priming blood before CPB might decrease inflammatory mediators in the blood and post-CPB inflammatory replications, thereby improving the respiratory function after CPB in infants. Sixty infants with a weight below 10 kg were divided randomly into two equal groups of CPB with the zero-balance ultrafiltration (Z-BUF) of priming blood and CPB without it. The procalcitonin level was measured before anesthesia, after admission to the intensive care unit (ICU), and 24 h afterward. The respiratory index and pulmonary compliance were measured after anesthesia, at the end of CPB, and 2 h after admission to the ICU. Additionally, time to extubation was recorded. The Z-BUF of priming blood maintained electrolytes within a physiologic level, and procalcitonin had a slighter rise in the Z-BUF Group at 24 h after admission to the ICU (P = 0.05). The respiratory index was decreased in the Z-BUF Group, but the difference with the control group did not reach statistical significance (P > 0.05). The change in pulmonary compliance was significantly increased in the cyanotic patients in the intervention group, but there was no significant difference between the two groups. The time to extubation and the ICU stay were shorter in the Z-BUF Group (P < 0.05). A positive correlation was found between the peak procalcitonin concentration and the time to extubation directly and pulmonary compliance reversely. These results suggest that the Z-BUF of priming blood may have some beneficial clinical effects such as improved respiratory function and attenuated procalcitonin., (© 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Endovascular stent implantation has become the treatment of choice for the management of patients with native coarctation of the aorta (CoA). The aim of this study was to compare the outcomes of self-expandable stenting (SES) with balloon-expandable stenting (BES) in the treatment of native CoA. In this single-center retrospective study, all patients who underwent SES or BES for the management of native CoA were enrolled. Patients were followed up for a median period of 35 (inter-quartile range 15 to 71) months. The primary outcome of interest was a composite end point consisted of death, surgical repair, re-stenting, re-ballooning, and hospital admission for hypertension crisis. The CoA diameter has changed from 3.2 ± 2.1 to 14.2 ± 4.0 mm in the BES group and from 4.6 ± 2.6 to 12.2 ± 3.7 mm in the SES group (both p <0.001). The procedure was successful with residual pressure gradient <20 mm Hg in 99.0% and 98.6% of patients in the BES and SES groups, respectively. Major adverse events occurred in 6 (8.7%) in the SES groups and 14 (20.3%) in the BES group (p = 0.053). Kaplan-Meier curve showed no difference between the 2 groups in terms of survival from major adverse events (p = 0.10), but when groups were matched for the propensity of stenting methods, SES was associated with lower major adverse events (p = 0.01). In conclusion, the SES and BES methods were safe and durable in our cohort with low rates of adverse events. After adjustment for the propensity of treatment with each stenting method, SES was associated with better outcomes. Regardless of the outcome of each method, it should be noted that the taken approach should be tailored to the patient's anatomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Knowledge of intravascular volume (IV) status of a hypotensive patient is of utmost importance. Clinical evaluation and central venous pressure (CVP) measurement are routinely used as a guide for evaluation of IV in these patients. However, clinical assessment may be inaccurate, and CVP measurement is invasive. Moreover, CVP changes slowly with saline therapy, which is unfavorable for fluid resuscitation., Aim: Our aim is to find the correlation and sensitivity of inferior vena cava (IVC) diameter measured by ultrasound to provide a noninvasive method for evaluation of IV among patients with hypotension and hypovolemia in the emergency department (ED)., Methods: We measured the IVC diameter of hypotensive patients before and after saline therapy. As all of the patients had central venous line (CV-line) in place, CVP was also measured before and after. Using MedCalc and SPSS software the correlation between these two was determined as expressed with " r ." Then, receiver operating characteristic (ROC) curve was sketched., Results: Ninety-nine patients, 49 (49.5%) males, were evaluated. Mean systolic blood pressure was 90 mmHg with a mean hazard ratio about 104. IVC diameter was 7.44 ± 5.13 mm before and 9.84 ± 5.29 after ( P = 0.002) saline therapy. There was a high correlation between IVC diameter and CVP ( r = 0.941, P < 0.0001 before saline therapy and r = 0.95, P < 0.0001 after saline therapy). ROC curve for IVC diameter shows a very high sensitivity for all criteria values., Conclusion: IVC diameter measurement using ultrasonography has excellent correlation with CVP. This method is very sensitive to rapid IV changes thus useful to guide saline therapy in hypotensive patients referred to ED. However, its use in certain subsets of patients' needs further studies., Competing Interests: There are no conflicts of interest.

Purpose: The purpose of the study was to evaluate tissue reaction to polycaprolactone (PCL) nanofiber patches in the cornea, conjunctiva, and anterior chamber (AC) in rabbit eyes and to assess their biocompatibility for use as patch grafts., Methods: Two 100 μ PCL patches were implanted under the conjunctiva and in the corneal stroma of one albino New Zealand rabbit, and pathologic evaluation was done after 3 weeks. In the next step, two PCL patches were implanted; one in the corneal stroma and the other in the AC of two rabbits followed by pathologic evaluation after 3 months., Results: On slit-lamp examination, there was minimum inflammation in all cases. Pathologic examination showed that the contact and probably merging between the host tissue and PCL fibers were achieved with minimal tissue reaction., Conclusion: As a biocompatible material, PCL nanofibers seem to be a promising modality for the repair of different tissue defects including melting, thinning, and perforation. They may also be a suitable material for manufacturing keratoprostheses.

Background and Aim: Effects of atrial fibrillation (AF) and its ablative treatment on LV torsion have not yet been fully investigated. This study aimed to examine whether AF patterns of LV contraction and its ablative correction can exert a significant impact on LV torsion by velocity vector imaging (VVI)., Methods: This case-control study conducted in Rajaie Cardiovascular, Medical and Research Center between October 2012 and June 2013. Study participants were 30 consecutive patients with symptomatic paroxysmal AF who met the inclusion criteria. The control group included 24 healthy participants with no history of cardiovascular disease. All individuals were in sinus rhythm at the time of echocardiography before and after the ablation procedure. Two-dimensional (2D) and Doppler echocardiography on a commercially available ultrasound system was performed for all the patients. Scanning was done by a wide-band ultrasound transducer with the frequency range between 2.5-3.5 MHz. The two short-axis views at basal and apical levels were subsequently processed off-line by VVI XStrain software. In order for data analysis, SPSS 16 utilized using paired and independent t-test. p-value ≤0.05 was considered significant., Results: LV torsion (°/cm) mean ± SD was significantly lower in paroxysmal AF patients before ablation (0.8±0.3) than the control group (1.5±0.4) (p<0.001) and increased significantly after ablation (1.1±0.5) compared with before ablation (p=0.004), but still significantly lower than the control group (p=0.003). LV Twist, twist rate and untwist rate mean ± SD were significantly lower in paroxysmal AF patients before ablation than the control group and increased significantly after ablation compared with before ablation, but still significantly lower than the control group., Conclusion: Subclinical LV dysfunction may be detected in paroxysmal AF rhythm by measuring torsional parameters through VVI which improves after AF ablation., Competing Interests: Conflict of Interest: There is no conflict of interest to be declared.

Background: Echocardiography is a key screening tool in the diagnostic algorithm of pulmonary hypertension (PH). In addition, tissue doppler imaging (TDI) is a promising method for the noninvasive estimation of pulmonary artery pressure (PAP)., Objectives: The aim of this study was to validate the accuracy of measuring the time from the beginning of the right ventricular isovolumetric contraction time (RV IVRT) to the peak of the S wave in the TDI of the base of the RV free wall (time to peak or TTP), as an indicator for the non-invasive estimation of pulmonary hypertension., Patients and Methods: In this diagnostic test study, 60 consecutive patients referred for right heart catheterization (RHC) were enrolled. A pulse-wave TDI was performed before the cardiac catheterization, with a mean interval of 1 hour between the two measurements. The TDI variables, such as the RV IVRT, myocardial performance index (MPI), and the new "time to peak" parameter, were measured at the lateral basal RV free wall. The patients were divided into two sub-groups according to the RHC findings: no-PH (mean PAP < 25 mmHg) and PH (mean PAP ≥ 25 mmHg) groups. Then, we calculated the specificity and sensitivity of the TDI parameters (including the TTP) for the diagnosis of PH., Results: In our study, the TTP showed a significant inverse relationship with the PAP. Based on our results, a TTP of less than 127 ms could be used to predict PH, with a sensitivity and specificity of about 70% (AUC = 0.746 ± 0.064)., Conclusions: Based on the results of this study, we suggest the use of a novel "time from the beginning of isovolumetric contraction to the peak of the S wave" (TTP) parameter in the TDI of the base of the RV free wall to predict PH with acceptable accuracy in comparison with RHC.

Background: Prolongation of the QT interval is considered a risk factor for cardiac adverse events and mortality. Left bundle branch block (LBBB) lengthens the QT interval. The corrected QT interval (QTc) is most likely overestimated because its prolongation is caused by increases in depolarization duration and not in repolarization., Objectives: In this study, we aimed to apply corrected JT interval (JTc) as an appropriate measure of ventricular repolarization for predicting QTc in a formula., Patients and Methods: The study population consisted of 101 patients with sinus rhythm (SR) and narrow QRS complexes (< 120 milliseconds). All patients underwent electrophysiology studies or ablation. A diagnostic catheter was positioned in the right ventricular apex (RVA) to induce LBBB at two different cycle lengths (CLs; 600 and 700 mv). The intrinsic QRS complex, QT time, and JT time were measured during SR and subsequent RVA pacing. The JTc was derived simply by subtracting the QRS duration from the QTc., Results: Stimulation from the RVA increased the QTc from 456.20 ± 38.63 ms to 530.67 ± 47.73 ms at a CL of 600 (P < 0.0001) and to 502.32 ± 47.26 ms at 700 CL (P < 0.0001). JTc showed no significant changes with stimulation from the RVA (102.97 ± 11.35 ms vs. 103.59 ± 10.67 ms, P = 0.24). There was no significant correlation between JTc and QRS complex duration. A significant correlation was seen between QRS and QTc at both CLs. The ROC curve indicated that sensitivity of 80% and specificity of 67% were obtained with JTc duration of 92.6 ms., Conclusions: Right ventricular pacing increases the QT interval without increasing the JT interval. Our results confirm that JTc, as an index of repolarization, is independent of ventricular depolarization. Therefore, it can be applied for predicting QTc in patients with LBBB.

Background: Radiographs, adjunct to clinical examination are always valuable complementary methods for dental caries detection. Recently, progressing in digital imaging system provides possibility of software designing for automatically dental caries detection., Objectives: The aim of this study was to develop and assess the function of diagnostic computer software designed for evaluation of approximal caries in posterior teeth. This software should be able to indicate the depth and location of caries on digital radiographic images., Materials and Methods: Digital radiographs were obtained of 93 teeth including 183 proximal surfaces. These images were used as a database for designing the software and training the software designer. In the design phase, considering the summed density of pixels in rows and columns of the images, the teeth were separated from each other and the unnecessary regions; for example, the root area in the alveolar bone was eliminated. Therefore, based on summed intensities, each image was segmented such that each segment contained only one tooth. Subsequently, based on the fuzzy logic, a well-known data-clustering algorithm named fuzzy c-means (FCM) was applied to the images to cluster or segment each tooth. This algorithm is referred to as a soft clustering method, which assigns data elements to one or more clusters with a specific membership function. Using the extracted clusters, the tooth border was determined and assessed for cavity. The results of histological analysis were used as the gold standard for comparison with the results obtained from the software. Depth of caries was measured, and finally Intraclass Correlation Coefficient (ICC) and Bland-Altman plot were used to show the agreement between the methods., Results: The software diagnosed 60% of enamel caries. The ICC (for detection of enamel caries) between the computer software and histological analysis results was determined as 0.609 (95% confidence interval [CI] = 0.159-0.849) (P = 0.006). Also, the computer program diagnosed 97% of dentin caries and the ICC between the software and histological analysis results for dentin caries was determined as 0.937 (95% CI=0.906-0.958) (P < 0.001). Bland-Altman plot showed an acceptable agreement for measuring the depth of caries in enamel and dentin., Conclusions: The designed software was able to detect a significant number of dentin caries and acceptable measuring of the depth of carious lesions in enamel and dentin. However, the software had limited ability in detecting enamel lesions.

Background: Invasive and continuous blood pressure (BP) monitoring is crucial after cardiac surgery. Accuracy of BP measurement mostly depends on patency of arterial catheter and acceptable waveform. Heparinized saline flush usually used for this purpose may be accompanied by potential heparin adverse effects., Objectives: The aim of this study was to compare heparinized and non-heparinized saline flush to maintain acceptable arterial waveform after cardiac surgery., Materials and Methods: In a double blind randomized trial study, 100 patients undergoing elective cardiac surgery were randomized to using heparinized (n = 50) or non-heparinized (normal) saline flush (n = 50) to maintain patency of arterial catheter after operation. Indwelling arterial catheters were checked daily for acceptable arterial waveform for three days as primary outcome measures., Results: Frequency of acceptable arterial waveform ranged from 66% to 80%, in first, second and third postoperative days. There were no statistically significant differences between heparinized and non-heparinized saline groups regarding acceptable arterial waveforms in all the three postoperative days (all P values > 0.05)., Conclusions: Using non-heparinized normal saline is suitable to maintain acceptable arterial waveform for short-term (three days) after adult cardiac surgery considering potential adverse effects of heparin.

Background: In orthodontic science, diagnosis of facial skeletal type (class I, II, and III) is essential to make the correct treatment plan that is usually expensive and complicated. Sometimes results from analysis of lateral cephalometry radiographies are not enough to discriminate facial skeletal types. In this situation, knowledge about the relationship between the shape and size of the sella turcica and the type of facial skeletal class can help to make a more definitive decision for treatment plan., Objectives: The present study was designed to investigate this relationship in patients referred to a dental school in Iran., Patients and Methods: In this descriptive-analytical study, cephalometric radiographies of 90 candidates for orthodontic treatment (44 females and 46 males) with an age range of 14 - 26 years and equal distribution in terms of class I, class II, and class III facial skeletal classification were selected. The shape, length, diameter, and depth of the sella turcica were determined on the radiographs. Linear dimensions were assessed by one-way analysis of variance while the correlation between the dimensions and age was investigated using Pearson's correlation coefficient., Results: Sella turcica had normal morphology in 24.4% of the patients while irregularity (notching) in the posterior part of the dorsum sella was observed in 15.6%, double contour of sellar floor in 5.6%, sella turcica bridge in 23.3%, oblique anterior wall in 20% and pyramidal shape of the dorsum sella in 11.1% of the subjects. In total, 46.7% of class I patients had a normal shape of sella turcica, 23.3% of class II patients had an oblique anterior wall and a pyramidal shape of the dorsum sella, and 43.3% of class III individuals had sella turcica bridge (the greatest values). Sella turcica length was significantly greater in class III patients compared to class II and class I (P < 0.0001). However, depth and diameter of sella turcica were similar in class I, class II, and class III patients. Furthermore, age was significantly correlated to the diameter of sella turcica as greater diameters were observed in older ages (P < 0.04)., Conclusion: A significant relationship exists between the type of facial skeletal classification and the shape of the sella turcica; as in class III patients, sella turcica bridge was reported with a higher frequency. Also, sella turcica had a significantly higher length in these patients than in those with class I and class II facial skeletal types.

Fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC) reverse oral anticoagulants such as Warfarin. We compared the standard dosage of FFP and PCC in terms of efficacy and safety for patients with mechanical heart valves undergoing interventional procedures while receiving Warfarin. Fifty patients were randomized (25 for each group) with mechanical heart valves [international normalized ratio (INR) >2.5]. FFP dosage was administered based on body weight (10-15 mL/Kg), while PCC dosage was administered based on both body weight and target INR. INR measurements were obtained at different time after PCC and FFP infusion. The mean ± SD of INR pre treatment was not significantly different between the PCC and FFP groups. However, over a 48-hour period following the administration of PCC and FFP, 76% of the patients in the PCC group and only 20% of the patients in the FFP group reached the INR target. Five (20%) patients in the PCC group received an additional dose of PCC, whereas 17 (68%) patients in the FFP group received a further dose of FFP (P=0.001). There was no significant difference between the two groups in Hb and Hct before and during a 48-hour period after PCC and FFP infusion. As regards safety monitoring and adverse drug reaction screening in the FFP group, the INR was high (INR > 2.5) in 86% of the patients. There was no report of hemorrhage in both groups. PCC reverses anticoagulation both effectively and safely while having the advantage of obviating the need to extra doses.

Background: The no-reflow phenomenon is an uncommon and critical occurrence which myocardial reperfusion does not restore to its optimal level. Several predisposing factors of the no-reflow phenomenon have been identified. However, at present we know little about clinical predictors of no-reflow after percutaneous coronary intervention (PCI)., Objectives: In this study, we evaluated clinical predictors of no-reflow phenomenon after PCI in patients with acute STEMI, to plan a better treatment of these patients., Patients and Methods: During an 18-month period, from 2013 to 2014, 438 patients with acute myocardial infarction (AMI) presenting within the first 24 hours from symptoms onset were treated with primary PCI in the Rajaie Cardiovascular Medical and Research Center. Thrombolysis in myocardial infarction (TIMI) flow was measured in all patients on the first angiography, following stenting. A total of 49 patients were allocated to the case group, based on the no-reflow phenomenon occurred during primary PCI (TIMI grade 0 and 1) and 50 patients without the no-reflow phenomenon (TIMI grade ≥ 3) were randomly selected, as the control group. They were evaluated from the point of demographic variables and also infarction territory, pain duration, maximal ST-change, left ventricle (LV) function, laboratory data, coronary anatomy, culprit vessel, location of lesion, target vessel diameter, lesion length, eccentricity, thrombus grade, tortuosity, lesion angulation, bifurcation, predilation, postdilation, thrombus aspiration, number of stent, in stent thrombosis. Data were then analyzed with the SPSS statistical software., Results: Mean age of patients was 59.47 (SD = 12.48) years, of which 75 (75.8%) were male and 24 (24.2%) were female. Based on univariable analysis, white blood cell (WBC) count, pain duration, LV function, maximal ST-change, thrombus grade and eccentricity were identified as predictors of the no-reflow phenomenon. After multivariable logistic regression: WBC count and thrombus grade remained the significant independent predictors of the no-reflow phenomenon (P < 0.05). In case group, slow-flow was seen in 42 (9.5%), while no-reflow was seen in seven (1.6%) patients., Conclusions: The WBC count and thrombus grade are strong, independent predictive factors of developing the no-reflow phenomenon, in AMI patients undergoing primary PCI. There is also an association between the no-reflow phenomenon and pain duration, maximal ST-change, LV function, high sensitivity C-reactive protein (hs-CRP), bifurcation, eccentricity and coronary anatomy.

Objective: There is conflicting data regarding the tricuspid annular velocities and their relation to right ventricular filling pressures. We aimed to assess if the time interval between the onset of tricuspid E wave and annular Ea wave has any correlation with right sided filling pressure in patients with heart failure., Methods: Thirty heart failure patients (left ventricular ejection fraction≤35%) were enrolled. Echocardiography was performed to obtain tricuspid inflow and tissue Doppler annular velocities just before a standard right heart catheterization. The right atrial pressure was obtained from right heart catheterization. The E/Ea [the ratio of peak velocity of early tricuspid inflow wave (E) to peak velocity of early diastolic wave of the lateral tricuspid annulus (Ea)] and the time intervals between the beginning of R wave of electrocardiogram and onset of E (TE) as well as between the beginning of R wave and onset of Et (TEa) were measured, TE-Ea was calculated as TE-TEa., Results: The mean right atrial pressure (RAP) was 8.8 (SD=4.7) mm Hg. The mean TE-Ea was + 8.61 milliseconds. There was no significant correlation between RAP and E/Ea (r=0.08, p>0.05) but the correlation between TE-Ea and RAP was significant (r=0.5, p=0.01)., Conclusion: According to our results and in contrary to some prior studies, we showed for the first time that right side TE-Ea stands as a better surrogate of right atrial pressure than E/Ea in heart failure patients. This finding needs more accurate studies and could present TE-Ea as a feasible tool to look into hemodynamics of heart failure patients.

Background: There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery., Objectives: The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital., Patients and Methods: We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours., Results: Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons)., Conclusions: In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery.

Background: The aim of this study was to examine the impacts of multiple indicators of Socio-economic Status (SES) on Congestive Heart Failure (CHF) related readmission., Methods: A prospective study consisting of 315 patients without the history of admission due to CHF was carried out in Tehran during 2010 and 2011. They were classified into quartiles based on their SES applying Principal Component Analysis (PCA), and followed up for one year. Using stratified Cox regression analysis, Hazard Ratios (HRs) were computed to assess the impact of SES on the readmission due to CHF., Results: During the 12 months follow-up, 122 (40%) were readmitted at least once. HR of lowest SES patients vs. the highest SES patients (the fourth versus first quartile) was 2.66 (95% CI= 1.51-4.66). Variables including abnormal ejection fraction (<40%), poor physical activity, poor drug adherence, and hypertension were also identified as significant independent predictors of readmission., Conclusion: The results showed low SES is a significant contributing factor to increased readmission due to CHF. It seems that the outcome of CHF depends on the SES of patients even after adjusting for some of main intermediate factors.

Background: The thyroid hormones influence on all metabolic pathways. After heart surgery using cardiopulmonary bypass (CPB), serum T3 decreases and remains low for at least 24 hours. Several studies on pediatric have reported reduction of thyroid hormones after heart surgery. This study aimed to investigate the status of thyroid function tests in children with CPB surgery., Methods: This study was carried out based on the available data on 132 children aged less than 15 years suffering from CHD. The patients underwent open heart surgery in Rajaie Center in Iran from January to November 2010. The thyroid hormone levels were measured shortly after admission, and postoperatively in Intensive Care Unit (ICU) and thereafter at 12, 24 and 48-hour intervals. The patients' gender, age, weight, body mass index, heart disease details, previous cardiac surgeries, and cardiac surgery-related data such as pump time, aortic clamping time, hypothermia duration, postoperative hemodynamic status and postoperative use of inotropic drugs were recorded and analyzed Results: All patients showed a decrease in T3, T4 and TSH and an increase in T3-resin uptake after surgery. Eventually, 3 (3.2%) patients died. Preoperatively, there was a significant association between the reduction in the thyroid hormone levels and inotropic drugs as well as the type of the heart disease (p<0.05)., Conclusion: There is an association between post-operative inotropic drugs administration and reduction thyroid hormones levels in patients undergoing congenital heart disease cardiopulmonary bypass surgery.

Background: Bacterial pericarditis is an important cause of post-surgery mortality and morbidity. This can be a preventable complication and the involved pathogens vary according to the time and location., Objectives: The aim of this study was to investigate the bacteriologic profile in patients with pericardial infections after cardiac surgery in the largest tertiary care center for cardiovascular diseases in Iran. The results can be applied for prevention, diagnosis, and treatment of similar patients in Iran., Patients and Methods: This prospective study was performed in Rajaie Cardiovascular Medical and Research Center (RCMRC), the largest tertiary care center for cardiovascular disease in Iran from March 2011 to March 2012. Patients who had undergone cardiac surgery with cardiopulmonary bypass and showed suggestive sign and symptoms of pericardial infections were registered and samples from their pericardial fluids were obtained to perform standard bacteriologic and antibiogram tests., Results: A total of 158 patients were registered. Bacteriologic findings were positive in 30 patients (19%). Staphylococcus epidermidis was the most frequent isolated organism, which was found in 22 patients (73.3%) with eight of them being methicillin-resistant strains., Conclusions: The bacteriologic profile in our patient is specific to our own community. Knowledge about this profile can help us to improve prevention, diagnosis, and treatment of the affected patients.

Background: Fibrinogen is the main biomarker for bleeding. To prevent excessive postoperative bleeding, it would be useful to identify high-risk patients before coronary artery bypass grafting (CABG)., Objectives: In order to predicating bleeding after CABG, we sought to determine whether preoperative fibrinogen concentration was associated with the amount of bleeding following CABG., Patients and Methods: A total of 144 patients (mean age = 61.50 ± 9.42 years; 65.7% men), undergoing elective and isolated CABG, were included in this case-series study. The same anesthesia technique and medicines were selected for all the patients. In the ICU, the patients were assessed in terms of bleeding at 12 and 24 hours post-operation, amount of contingent blood products received, and relevant tests. Statistical tests were subsequently conducted to analyze the correlation between preoperative fibrinogen concentration and the amount of post-CABG bleeding., Results: The mean ± standard deviation of bleeding at 12 and 24 hours post-operation was 285.37 ± 280.27 and 499.31 ± 355.57 mL, respectively. The results showed that postoperative bleeding was associated with different factors whereas pre-anesthesia fibrinogen was not correlated with bleeding at 12 (P = 0.856) and 24 hours (P = 0.936) post-operation. There were correlations between the extra-corporal circulation time and bleeding at 12 hours post-operation (ρ = 0.231, P = 0.007) and bleeding at 24 hours post-operation (ρ = 0.218, P = 0.013)., Conclusions: Preoperative assessment of plasma fibrinogen levels failed to predict post-CABG bleeding.

Background: Prolactin (PRL) has increasingly been recognized to play a stimulatory role in inflammatory response. Recently, studies have reported an increase in prolactin level among patients with chronic heart failure, however, there is conflicting data about its role as a prognostic factor in these patients., Objectives: We aimed to measure PRL level in male patients with idiopathic dilated cardiomyopathy (IDC) and its relationship with some prognostic factors., Patients and Methods: Serum prolactin level was assessed in 33 men with a diagnosis of IDC, left ventricle ejection fraction (LVEF) less than 35% on standard medical therapy for heart failure and New York Heart Association class II-III. Serum NT-Pro BNP (N terminal pro brain natriuretic peptide), hs-CRP (High sensitive C reactive protein) and six-minute walk test (6MWT) were also measured. Our secondary endpoints were mortality, transplantation and hospitalization due to acute heart failure and all patients were followed for one year., Results: The mean age was 33 ± 7 years (24-45 years) and the mean LVEF was 23% ± 6.5. The mean PRL level was 16 ± 7.7 ng/mL (95% confidence interval: 13.3-18.7 ng/mL), which was significantly higher than normal reference values (4.04-15 ng/mL) (P < 0.0001). There was no correlation between PRL levels and pro BNP, hs-CRP or 6MWT test, however, the serum PRL level was slightly higher among patients who died or were hospitalized or transplanted., Conclusions: Considering our study results, prognostic implication of PRL should be questioned. However, it seems that the significant increase in serum PRL in the study population needs more consideration and may have its own pathophysiologic importance. Further studies are recommended for better addressing the role of PRL in chronic heart failure patients.

Background: The prevalence of Metabolic syndrome (MetS) has been increased in Asian countries. It represents a cluster of cardiovascular risk factors including obesity, insulin resistance, lipid abnormality and hypertension., Objectives: The purpose of this study was to assess the association between MetS and outcome in patients undergoing coronary artery bypass grafting surgery (CABG)., Patients and Methods: This prospective study was performed on patients scheduled for coronary artery bypass grafting surgery (CABG). All the patients were followed up in hospital and three months afterward. Patients were excluded if they were younger than 18 years or had severe comorbidities, a history of valvular heart disease, and low ejection fraction., Results: A total of 235 patients (135 women) with a mean age of 59 ± 9.3 years were included. MetS was more prevalent in women (P < 0.001). The most prevalent complications were bleeding [20 (8.5%)] and dysrhythmia [18 (7.7%)]. At three months follow-up, the frequency rates of readmission [24 (10.2%)] and mediastinitis [9 (3.8%)] were higher than other complications. Diabetes and MetS were risk factors for a long ICU stay (> 5 days) and atelectasia (P < 0.05). Significant associations were observed between diabetes and pulmonary embolism (P = 0.025) and mediastinitis (P = 0.051)., Conclusions: Identification of MetS before CABG can predict the surgery outcome. Patients with MetS have increased risks for longer ICU stay and atelectasia.

Background: Recent studies have introduced glucose intolerance and insulin resistance (IR) as novel risk factors in patients with pulmonary arterial hypertension (PAH)., Objectives: We aimed to investigate the prevalence of glucose intolerance and IR in patients with PAH and their correlation with functional capacity and prognostic factors., Patients and Methods: Sixty-nine patients with pulmonary arterial hypertension (class I Pulmonary hypertension in accordance with updated clinical classification of pulmonary hypertension) scheduled for right heart catheterization were enrolled. FBS, HbA1c, lipid profile, pro -BNP and hs-CRP were measured along with a 6-minute walk test (6-MWT) and obtaining demographic, functional and hemodynamic data. Fasting triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) was used as a surrogate of insulin sensitivity. Using published criteria, HbA1c ≤ 5.9% defined as normal, 6.0-6.4% as glucose intolerance, and ≥ 6.5% as diabetes. All patients were followed for a year regarding development of any cardiovascular event (mortality and/or hospitalization)., Results: In total, 76.8% of patients were female: 61% of them had idiopathic PAH, 33% Eisenmenger syndrome, and 6% PAH secondary to a connective tissue disease. With respect to TG/HDL-C, 43.5% of patients had IR and 47.8% of patients had HbA1c > 6. There was no difference between IR and insulin sensitive (IS) group or glucose intolerance and sensitive group regarding NYHA class, 6MWT, Pro BNP, hs-CRP and hemodynamic data and there was no correlation between IR or glucose intolerance and any event., Conclusions: Unrecognized glucose intolerance and IR are common in PAH. However, further studies are needed to show whether glucose or insulin dysregulation plays any role in PAH pathogenesis or it is secondary to advanced PAH.

Purpose: To compare different preparation methods for a suitable amniotic membrane (AM) extract containing a given amount of growth factors., Methods: In this interventional case series, we dissected the AM from eight placentas within 24 hours after delivery, under clean conditions. After washing and mixing, AM extracts (AMEs) were prepared using pulverization and homogenization methods, and different processing and storing conditions. Main outcome measures were the amount of added protease inhibitor (PI), the relative centrifugal force (g), in-process temperature, repeated extraction times, drying percentage, repeated pulverization times, and the effect of filtering with 0.2 μm filters. Extract samples were preserved at different temperature and time parameters, and analyzed for hepatic growth factor (HGF) and total protein using ELISA and calorimetric methods, respectively., Results: The extracted HGF was 20% higher with pulverization as compared to homogenization, and increased by increasing the PI to 5.0 μl/g of dried AM. Repeating centrifugation up to 3 times almost doubled the extracted HGF and protein. Storing the AME at -170° for 6 months caused a 50% drop in the level of HGF and protein. Other studied parameters showed no significant effect on the extracted amount of HGF or total protein., Conclusion: Appropriate extraction methods with an adequate amount of PI increases the level of extractable components from harvested AMs. To achieve the maximal therapeutic effects of AMEs, it is necessary to consider the half-life of its bioactive components.

Background: This study attempted to identify the role of combined conventional and novel echocardiographic techniques in evaluation of left atrial (LA) function to predict the postoperative atrial fibrillation (POAF)., Methods: In this cross-sectional study, subjects with sinus rhythm who were candidates for CABG were enrolled. Preoperative LA function was evaluated by conventional echocardiography and 2-dimensional strain imaging based-velocity vector imaging (VVI). VVI-derived systolic peak positive, early and late diastolic strain rate were measured. Using tissue Doppler study, systolic peak velocities (Sm), early diastole (Em), atrial systole (Am) and AEMi were also measured. The patients were observed during their hospital stay. The primary endpoint of the study was postoperative AF lasting > 5 minutes., Results: POAF occurred in 12.7% of patients. Age, LA volume index (LAVI), LA area, LA empting fraction (LAeF) and cardiopulmonary bypass time were found to be the independent predictors of POAF. TDI-derived velocities were similar in study groups. LA systolic strain rate (SRs) and early diastolic strain rate were impaired in patients with no significant difference between those who developed POAF and those who did not., Conclusions: Conventional echocardiography could be used as a feasible method for evaluating subclinical atrial dysfunction in patients undergoing CABG and the use of VVI- based 2-dimensional strain imaging may need further studies.

Objective: The goal of this study was to evaluate preoperative anxiety and its predisposing factors in a group of adult patients who were candidate for any kind of heart surgery., Methods: We evaluated preoperative anxiety in 300 patients undergoing heart surgery whose ages ranged between 18-65 years. Relationship of probable demographic factors like gender, educational level, marital status, number of children, family support, opium addiction, occupational status, and left ventricular ejection fraction (LVEF) with anxiety level of the patients were evaluated. To determine anxiety, the State-Trait Anxiety Inventory (STAI) was completed by the subjects., Results: Descriptive anxiety levels showed that mean of state and trait anxiety of our studied patients were in moderate scaling. Correlation between state and trait anxiety was more prominent in females (r = 0.80) than in males (r = 0.70) (p < 0.001). Distribution of males and females was significantly different (p = 0.048). All the patients had significantly different underlying diseases (p = 0.018), opioid addiction (yes/no) was significantly different in all of the patients (p < 0.001), while family support (yes/no) was not significantly different in all of the patients (p = 0.453). There were significant differences between mean of preoperative anxiety at different LVEF values of any EF level (p < 0.001, F = 6.47); those who had LVEF of more than 50% had significantly lower mean anxiety scores., Conclusion: Preoperative psychiatric consultation should be focused more on women and patients with higher EF. Moreover, physical activity strength may be effective on reducing preoperative anxiety.

Background: Nutrition is among the most important factors influencing coronary artery disease., Objectives: Here we aimed to study the nutritional status of patients with and without coronary artery disease (CAD)., Patients and Methods: We performed a cross-sectional study on 600 patients referred to a cardiology clinic with the signs of ACS. The patients were then classified in to two groups (CAD group and the normal group) based on angiographic findings. The amount of nutritional profile was questioned from all participants., Results: Men were more often diagnosed with CAD compared to women (198/362 vs. 102/238; P < 0.01). Patients with coronary artery disease were mostly older, smoker, coffee and black tea drinker had a higher BMI and more frequently diagnosed with hypertension, hyperlipidemia and diabetes. On the other hand, green tea consumption was seen more in women (92/238 vs. 115/362; P < 0.05) and those with regular physical activity (119/299 vs. 88/301; P < 0.01). Backward regression modeling was employed to study the predictors of CAD. Type of tea and meat remained as one the most important nutritional factors predicting CAD., Conclusions: White mean and type of tea were the most important predictors of CAD. Dietary prevention strategies from childhood could prevent early CAD.

Background: The current trend of heart transplantation in recent years has taken a quantum leap forward. We decided to look back at our experience in this center., Objectives: Here, we focus on the diagnostic pitfalls and challenges in these biopsies., Patients and Methods: Forty two patients based on the standard protocol of heart transplantation group, yielded 63 biopsy samples over a period of 33 months (April 2010 - December 2012). The mean age was 30.4 years (ranging from 16 to 58 years) with 51 males (81%) and 12 females (19%). All the patients were examined periodically and biopsy samples were taken from the right ventricular wall., Results: Rarely fewer than three pieces of myocardial samples were procured. Scar, adipose tissues and blood clots may be seen instead. Quilty effect (nodular endocardial lesions composed of inflammatory cell infiltrates) was seen in 8 cases (12.7%). Other findings not directly related to rejection including early ischemic injury, Quilty effect and post-transplant lymphoproliferative disorders (PTLD) were not encountered., Conclusions: Specimen inadequacy was not a major problem in our center. It poses a great limitation, because suboptimal specimens sometimes mislead the pathologist. Other findings especially Quilty effect were within the range defined for this finding.

Introduction: Pulmonary valve replacement (PVR) is being performed more commonly late after the correction of tetralogy of Fallot. Most valves are replaced with an allograft or xenograft, although reoperations are a common theme. Mechanical prostheses have a less favorable reputation due to the necessity of lifelong anticoagulation therapy and higher risk of thrombosis, but they are also less likely to require reoperation. There is a paucity of data on the use of prosthetic valves in the pulmonary position. We report the midterm outcomes of 38 cases of PVR with mechanical prostheses., Methods: One hundred twenty two patients who underwent PVR were studied. Thirty-eight patients, mean age 25 ± 8.4 years underwent PVR with mechanical prostheses based on the right ventricular function and the preferences of the patients and physicians. Median age of prosthesis was 1 year (range 3 months to 5 years)., Results: Seven (18%) patients had malfunctioning pulmonary prostheses and two patients underwent redo PVR. Mean International Normalized Ratio (INR) in these seven patients was 2.1±0.8. Fibrinolytic therapy was tried and five of them responded to it well. There was no significant association between the severity of right ventricular dysfunction, patient's age, prostheses valve size and age of the prosthesis in the patients with prosthesis malfunction., Conclusion: PVR with mechanical prostheses can be performed with promising midterm outcomes. Thrombosis on mechanical pulmonary valve prostheses remains a serious complication, but most prosthesis malfunction respond to fibrinolytic therapy, underscoring the need for adequate anticoagulation therapy.

Background: Tissue Doppler imaging is used routinely to quantify both left and right ventricular function. However, normal reference values of echocardiography parameters of the right ventricle in Iranian population are still unknown., Objectives: Accordingly, we conducted a study to determine the normal values of echocardiography parameters of right ventricular function in a healthy Iranian population., Patients and Methods: One hundred and eighty seven healthy volunteer subjects enrolled. Normal subjects were chosen by taking into account history, physical examination, ECG and echocardiography., Results: Reference ranges (5th and 95th percentile values) for tricuspid E velocity, A velocity, E/A ratio, deceleration time, annular Sa velocity, Ea velocity, and E/Ea ratio were derived for the whole individuals and for each of the three age groups (< 30, 30-39, 40-49). The deceleration time, E/ Ea ratio and acceleration time of the iso-volumetric contraction time (IVA) were greater in male than in female. All measured parameters were bigger but not statistically significant in the 40-49 year-old group in comparison with the < 30 year-old group. Comparison of data between different groups showed no significant differences between the majority of data when they have been adjusted to body surface area, age and sex., Conclusions: The reference ranges presented for the echocardiography parameters of right ventricular function, albeit not conducted in a sizable sample of normal cases, will help to standardize the assessment of RV functions, particularly by tissue Doppler imaging.

Atrial fibrillation (AF) is associated with inflammatory and hypercoagulability state. Previous studies evaluated the safety and efficacy of dabigatran and warfarin in prevention of thrombothic complications. This study was intended to assess the influence of these drugs on hemostatic and inflammatory markers among patient underwent pulmonary vein ablation. A total of 100 patients with AF who underwent catheter ablation were randomized to treatment with dabigatran (D) 110 mg twice daily or warfarin (W) adjusted to an international normalized ratio (INR) of 2.0 to 3.0 for 3 months after ablation procedure. C - reactive protein (CRP), D-dimer, prothrombin fragment F1 + 2 (F1 + 2), were measured at baseline before ablation procedures, after 30 days and after 90 days of treatment. After 3 months, the D-dimer was 164.9 ± 48.9 in Dabigatran and 197.2 ± 58.6 in warfarin group, F1 + 2 was 0.4 ± 0.2 in dabigatran and 0.8 ± 0.2 in warfarin group and CRP level was 1.8 ± 1.6 in Dabigatran and 5.1 ± 5 in warfarin group. (All p-values < 0.05) The results showed that treatment with dabigatran made greater changes in the serum level of CRP, D-dimer, F1 + 2. The pattern of changes in serum CRP levels D-dimer, F1 + 2 is much faster and with a greater slope in the dabigatran group.

Background: Tricuspid regurgitation (TR) is a common echocardiographic finding, which often accompanies left sided valve disease. Data on mortality and morbidity in patients with severe TR are limited., Objectives: We sought to assess the outcome of patients with severe TR with the hypothesis that significant TR adversely impacts quality of life and survival, independent of pulmonary artery pressure (PAP) and left ventricular ejection fraction (LVEF)., Materials and Methods: Between 2002 and 2012, 358 consecutive patients (mean age of 54.67± 13.25years, 75.5% female) with severe TR based on history and transthoracic echocardiography (TTE) were enrolled. Patients with severe left sided valvular heart disease and congenital heart disease were excluded. The prevalence of heart failure symptoms, rehospitalization, and duration of hospitalization were evaluated. Survival was calculated according Kaplan Meier curve analysis., Results: Heart failure (50%) was the most cause of death. Mean years of survival from diagnosis of severe TR was 4.35±3.66, and mean years of survival from onset of symptom was 2.28±1.40. Ninety cases (25.1%) were admitted due to heart failure and through mean of 1.9±0.8 year- follow up (6-32month), 14% of all patients and 36.8% of patients with right heart failure rehospitalized. Atrial fibrillation was reported in 70.5% of patients., Conclusions: There is a significant increased incidence of mortality, prolonged hospitalization, and rehospitalization in symptomatic patients with severe TR. Therefore, we recommend more aggressive approach toward TV repair or replacement in these patients regardless of PAP and systolic function.

With advent of transcatheter aortic valve implantation, using multislice computed tomography (MSCT) to provide detailed data about aortic root has become more crucial. We compared aortic dimension changes during cardiac cycle in patients with and without aortic valve calcification and evaluated its correlation with aortic valve calcium score in former group. Fifty-two patients with and 52 subjects without aortic valve calcification underwent coronary MSCT using two 64-slice and a dual-source 256-slice CT scanners. Aortic root dimensions were measured in both systolic and diastolic phases. Changes in annular maximum diameter (D(max)), minimum diameter (D(min)), cross sectional area and perimeter, three diameters of sinuses of Valsalva (V(a), V(b) and V(c)), sinotubular junction maximum (STJ(max)) and minimum (STJ(min)) diameters between systolic and diastolic phases (systole minus diastole) were -0.59 mm, -0.05 mm, -2.53 mm(2), -1.48 mm, +0.91 mm, +1.08 mm, +0.42 mm, +0.63 mm, +0.40 mm and in those without aortic calcification -0.33 mm, 0.00 mm, -6.92 mm(2), -0.41 mm, +0.30 mm, +0.38 mm, +0.61 mm, +0.33 mm, +0.20 mm in patients with aortic calcification, respectively. Apart from two diameters in sinuses of Valsalva (V(a) and V(b)), changes in all other diameters of aortic root during cardiac cycle were not significantly different between the two groups. Furthermore, in patients with aortic calcification, no significant correlation was detected between changes in nearly all aortic root dimensions during cardiac cycle and aortic valve calcium score or location of calcification (annular, commissural or both).

Etiological factors for coronary artery disease (CAD) involve a wide range of gene and environmental interactions. One of the systems being implicated in the pathophysiology of CAD is the renin-angiotensin system (RAS). However, the genetic polymorphisms of this system have not been widely studied in Iranian patients diagnosed with CAD. The aim of this study was to assess the relationship between six gene polymorphisms of RAS components and CAD in a sample of Iranian population. A total of 374 participants were enrolled in a case/control study. The presence of CAD was determined by coronary angiography. Genotyping of six RAS gene polymorphisms was performed using a modified PCR-RFLP method. Our results revealed, for the first time, a significant independent association of angiotensin-converting enzyme (ACE) A-240T polymorphism and incidence of CAD among Iranian women (P=0.005, OR=20.4, 95% CI=2.49-41.2). There has also been a significant difference in genotype distribution of ACE A-240T (P=0.008) and angiotensin II receptor type 2 C3123A polymorphism (P=0.032) in Iranian female participants. In conclusion, TT genotype of ACE A-240T seems to be a genetic risk factor for CAD in Iranian women.

Background: According to previous studies on the deformation properties of the left atrium, the systolic strain and strain rates represent the atrial reservoir function and the early and late diastolic strain rates show the conduit and booster functions, respectively., Objectives: We sought to evaluate the intra and interatrial asynchrony using strain/strain rate imaging in systolic heart failure patients., Patients and Methods: Twenty five patients with systolic heart failure (LVEF ≤ 40%) were enrolled into the study. Asynchrony quantifications were performed according to the standard deviation of time-to peak (TP-SD) of deformation of three segments manually located along the perimeter of the left atrium free wall, right atrium free wall and interatrial septum, as imaged in an apical four-chamber view. We also calculated classic echocardiography parameters such as LV end-diastolic dimension index, LA volume index, RA area, as well as deceleration time (DT) on transmitral pulsed wave Doppler and E/E' ratio on mitral annular tissue Doppler imaging., Results: In heart failure patients either inter or intra-atrial asynchrony were far more common in comparison with normal subjects (P=0.008 and P=0.007 respectively)., Conclusions: Left ventricular systolic heart failure, may result in inter and intra-atrial asynchrony even in clinically stable patients without significant pulmonary hypertension and diastolic dysfunction.

Background: Pulmonary blood flow may affect lung development in adulthood. Early total correction of tetralogy of Fallot may affect development of final lung volumes. We evaluated the effect of age at total correction on lung volumes years after the operation., Methods: In a retrospective cohort study on patients with totally corrected tetralogy of Fallot (mean age, 13.40 years at the time of follow-up), forced vital capacity, slow vital capacity, forced expiratory volume in 1 s, and other parameters were measured 154.8 ± 46.25 months after the operation. Comparison were made of 3 groups: ≤2-, 2-8-, and >8-years old at the time of total correction surgery., Results: Among 322 enrolled patients, the mean values of the follow-up spirometry results in ≤2-, 2-8-, >8-year-olds and the percentage of predicted values were respectively: vital capacity: 4.46 ± 0.57 L (107% ± 10.96%), 3.89 ± 0.58 L (91.10% ± 12.25%), 3.25 ± 0.48 L (82.35% ± 10.62%), p < 0.001; forced vital capacity: 4.28 ± 0.63 L (95.90% ± 18.77%), 3.76 ± 0.58 L (90.83% ± 12.52%), 3.14 ± 0.49 L (83.26% ± 11.71%), p < 0.001; forced expiratory volume in 1 s: 4.22 ± 0.63 L (104.84% ± 13.64%), 3.66 ± 0.58 L (90.61% ± 12.59%), 3.02 ± 0.48 L (84.31% ± 12%), p < 0.001., Conclusion: Early correction of defects or reestablishments of perfusion of tetralogy of Fallot before completion of lung development might improve final adulthood lung volumes and capacities. It is better to consider total correction for all tetralogy of Fallot patients below 2-years old, or at least below 8-years old, if it is technically possible.

Pulmonary vascular resistance (PVR) has important prognostic implications in the assessment of patients with pulmonary hypertension. Using echocardiography to measure PVR would have the advantage of being able to follow patients serially and to assess their response to treatment noninvasively. The authors sought to assess whether right ventricular strain rate imaging (SRI) can predict PVR in patients with pulmonary hypertension. The study population consisted of 46 patients referred for right heart catheterization. The inclusion criteria was mean pulmonary artery pressure ≥25 mm Hg in right heart catheterization in patients with pulmonary hypertension including chronic systolic heart failure. Echocardiography was performed to obtain SRI just before right heart catheterization. Mean values of peak systolic longitudinal strain and strain rate obtained from basal and mid-right ventricular free wall were calculated. The control group consisted of 35 healthy adults matched for age and sex. The most significant correlations were between basal right ventricular strain and strain rate (SR) and mean pulmonary arterial pressure (r=0.63, P=.000), transpulmonary gradient (r=0.6, P=.001), and PVR (r=0.5, P=.003). SR was independently correlated with PVR (PVR=26.9-16.9×basal right ventricular SR; r=0.53, P=.003). The present study shows that basal right ventricular free wall strain and SR could be independently correlated with PVR in patients with pulmonary hypertension., (© 2012 Wiley Periodicals, Inc.)

Background: Intrapulmonary shunt as a result of atelectasis following cardiac surgeries is an important and common postoperative complication that results into pulmonary dysfunction typically lasting more than a week following surgery. Different methods have been provided to prevent these complications., Objectives: In order to prevent postoperative pulmonary complications, investigation of the effectiveness of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) during cardiopulmonary bypass (CPB) in patients undergoing coronary artery bypass grafting (CABG)., Materials and Methods: In this prospective interventional study, 300 patients, candidate for elective CABG (On-Pump), were randomly allocated to 3 groups: A, B, C. Group A (CPAP) patients received CPAP at 10 cm H2O during CPB. Group B (IMV) patients received IMV with a tidal volume of 2 cc/kg and respiratory rate of 15/min and group C (control) patients did not receive any type of ventilation during CPB. Other procedures were similar between groups. Arterial blood samples were taken at 8 moments and arterial blood gas (ABG) analysis were compared between groups. Chest x-rays after CABG were also evaluated with respect to atelectasis., Results: The demographic data were similar in between three groups. Graft number, pump time and preoperative ABGs were not significantly different. Postoperative PaO2 were significantly higher in the CPAP and IMV groups and (A-a) DO2 were significantly lower in these two groups, compared to the control group., Conclusions: In the present study, applying positive airway pressure methods (CPAP or IMV) during CPB was associated with better postoperative ABG measurements and (A-a) DO2.

Background: Catheter Related Blood stream Infections (CRBSI) are prevalent and a potentially fatal complication pertaining to cardiovascular implant devices. There have been no major studies on bacterial colonization of catheters in cardiovascular patients in Iran., Objectives: To evaluate the incidence of catheter colonization of bacteria in the largest Iranian cardiovascular center., Patients and Methods: March 2011 to 2012, Cauterization procedures performed on 60 patients hospitalized in Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, with arterial or venous catheterization, inserted 48 hours or more, catheter evaluations done by culture methods. Blood cultures were also obtained simultaneously., Results: Forty-four out of 60 catheters (73.3%) were positive with a significant colony count. Of 44 positive cases, 11 patients had positive blood culture. Three most frequently isolated microorganisms were Staph Albus [14 (32%)], Entrococcu [12 (27%)] and Acinetobacter [5 (11%)]. gram-positive cocci were sensitive to Vancomycin and Linezolid and gram-negative bacilli were sensitive to Amikacin, Gentamicin, Tobramycin and Imipenem., Conclusions: The study findings revealed that the catheter infection in our patients had sources other than normal skin flora. These results will assist in determining the possible source of the infections, furthermore, how they are transmitted, moreover aid in controlling and preventing these dangerous in- infections.

Background: There has been debate regarding whether natriuretic peptides can be used as a marker to distinguish cardioembolic (CE) origin of ischemic stroke from other subtypes. Therefore, the aim of this study was to study the value of N-terminal pro B-type natriuretic peptide (NT-proBNP) in differentiating CE from other subtypes of stroke in patients with acute ischemic stroke., Methods: All 125 consecutive patients with acute ischemic stroke in a 1-year period were included. Admission blood samples of all patients were analyzed for the serum level of NT-proBNP. Patients were evaluated for etiology of stroke by imaging modalities and classified based on Trial of Org 10172 in Acute Stroke Treatment criteria. Medical history and risk factors for vascular diseases were also obtained. Receiver operating characteristic (ROC) analysis was used for estimating the diagnostic performance of NT-proBNP levels., Results: Patients were a mean of 67.5 ± 12.6 years of age, and 60 (48%) were men. The most frequent subtype of stroke (57 patients) was CE (45.6%). Levels of NT-proBNP at admission were significantly higher in the CE group (P = .001). After omitting confounding variables, NT-proBNP levels and age were independent predictors of CE stroke subtype. ROC analysis revealed that the diagnostic performance of NT-proBNP levels (area under the curve), optimum cutoff point and its sensitivity and specificity were 0.882 ± 0.031pg/mL, 342 pg/mL, 93%, and 75%, respectively., Conclusions: NT-proBNP has an acceptable diagnostic value in distinguishing CE ischemic stroke from other subtypes. It can be used to differentiate the stroke subtype and facilitate the treatment process in these patients., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the natural history of aortic regurgitation (AR) in patients undergoing mitral valve procedures for mitral stenosis., Objectives: The aim of this study was to evaluate the short- and long-term effects of percutaneous mitral valvuloplasty (PMV) on coexisting AR., Materials and Methods: A total of 327 patients with rheumatic mitral stenosis (282 females and 45 males; mean age at the time of intervention = 47 ± 11 years) were followed up for between 48 hours and 13 years after PMV. At the time of PMV, 142 (43.3%) patients had no AR, 124 (37.9%) had mild AR, and 61 (18.7%) had moderate AR. After PMV, the follow-up showed that 120 (36.6%) patients had no AR, 103 (31.5%) had mild AR, and 104 (31.8%) had moderate AR., Results: AR progression after PMV and during the follow-up was significant (P < 0.00), but there was no significant increase in aortic valve replacement (AVR) procedures. The rate of AVR was higher in the moderate AR group (3.8%). There were no significant changes in the left atrial size (LA) (P = 0.6), ejection fraction (EF) (P = 0.4), and rhythm (P = 0.4) before and after PMV, respectively., Conclusions: Our findings indicate that among patients with rheumatic mitral stenosis, a considerable number have concurrent AR. Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcomes. Rheumatic aortic insufficiency progresses slowly by nature, and patients with AR and mitral stenosis can safely tolerate PMV without the possibility of undergoing AVR in the near future. Patients with moderate degrees of AR remain good candidates for PMV.

Background: Significant elevation of cardiac biomarkers after percutaneous coronary intervention (PCI) is associated with increased mortality. However, clinical importance of lesser degrees of cardiac enzyme elevation has not been well understood. Multiple factors might have an etiologic role, and the incidence of myonecrosis has not changed dramatically despite pharmacological and technological advances in PCI. The aim of this study was to evaluate the role of intracoronary (IC) Adenosine in preventing the elevation of cardiac enzymes as a marker of myonecrosis after PCI in patients with chronic stable angina., Methods: Two hundred sixty patients with chronic stable angina who were candidates for PCI were randomly assigned to double-blinded pretreatment with IC Adenosine or placebo before crossing of the guide wire. The patients were observed during the hospital course, and blood samples were obtained in standard intervals after the intervention for cardiac biomarkers. The primary end point of this study was post-PCI myonecrosis, and secondary end point was safety of IC Adenosine administration in the setting of PCI in patients with chronic stable angina., Results: Of the 260 patients, who were initially randomized, finally 83 patients were analyzed in the placebo and 96 in the Adenosine arms. The study patients were comparable in clinical and angiographic characteristics. The mean of the patients' age was 57.3 years (range = 35 to 79 years), and 71.5% were male. There were no differences in the mean serum cardiac biomarkers between the study groups (mean creatine kinase-MB [CK.MB] level of 29.5 ± 14.5 IU/L in the placebo group and 31.5 ± 18.5 IU/L in the control group; p value = 0.41; mean cardiac troponin I (cTnI) level of 0.097 ± 0.178 μg/L in the placebo group and 0.167 ± 0.5 μg/L in the control group; p value = 0.24)., Conclusion: Despite promising results in primary PCI, our study showed that a strategy of IC Adenosine pretreatment is not beneficial in reducing post-PCI myonecrosis in patients with chronic stable angina and should not be routinely used.

Purpose: The aim of this study was to assess the prevalence of impaired glucose metabolism in patients who attended hospital-based cardiac rehabilitation., Methods: We performed a single-group cross-sectional study. In a 7-month period, from September 2010. The study was conducted in a cardiac rehabilitation setting at a university hospital. Overall, 273 patients, with an established diagnosis of ischemic heart disease, who were referred to the cardiac rehabilitation center, were included. The primary outcome measure was the prevalence of impaired glucose metabolism. We also compared cardiovascular disease risk profile among participants., Results: One hundred twenty-one participants (44%) had diabetes mellitus, of which, for 80 patients, the diagnosis was previously established. Of the 193 patients without a previous diagnosis of diabetes, 52 patients (27%) had normal glucose levels, 41 (21.2%) had diabetes, 51 (26.4%) showed impaired glucose tolerance, and 49 (25.4%) had isolated impaired fasting glucose according to the American Diabetic Association criteria. Consistent with the World Health Organization criteria, 27 patients (14%) would have had isolated impaired fasting glucose and using fasting criteria alone, 22 patients would have had undiagnosed diabetes., Conclusion: Impaired fasting glucose and impaired glucose tolerance did not identify the same patients. It seems that both fasting plasma glucose and oral glucose tolerance test are necessary in the diagnosis of impaired glucose metabolism in patients with coronary artery disease.

Genetic factors contribute substantially to the likelihood of developing major depressive disorder (MDD). The importance of renin-angiotensin system (RAS) elements in cognition and behaviour and their involvement in aetiology and treatment of depression imply that RAS gene polymorphism(s) associated with RAS overactivity might also be associated with depression. In the present study, genotype and allele frequencies of six common polymorphisms of genes encoding for RAS components were determined in DNAs extracted from venous blood of 191 depressed and 104 healthy individuals using polymerase chain reaction (PCR) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and serum angiotensin-converting enzyme (ACE) activity was assayed using a high-performance liquid chromatography (HPLC) method. The results showed, for the first time, that GG genotype of ACE A2350G was significantly associated with MDD among Iranian participants (P=0.001; odds ratio (OR)=6.2; 95% confidence interval (CI)=2.1-18.3). Significant higher serum ACE activity (P=0.0001) as well as higher diastolic blood pressure (P=0.036) were observed in depressed patients compared to the healthy control group. Depressed patients carrying GG genotype of the A2350G polymorphism had a significantly higher serum ACE activity (P=0.02) than individuals with either AA or AG genotype. In conclusion, this study supports the hypothesis of RAS overactivity in depression in that the genotype associated with higher serum ACE activity in an Iranian population was also associated with MDD., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Percutaneous balloon mitral valvuloplasty is the preferred therapeutic strategy in patients with mitral stenosis, but it has shortcomings in a subset of patients., Hypothesis: A new method of balloon sizing through echocardiographic measurement of the intercommissural diameter would be safe and effective and lead to better outcomes., Methods: Eighty-six mitral-stenosis patients were randomly assigned to undergo balloon mitral valvuloplasty either with height-based balloon reference sizing (HBRS group, n = 43) or with balloons sized by the echocardiographic measurement of intercommissural diameter (EBRS group, n = 43). Postprocedural mitral valve area (MVA) and severity of mitral regurgitation (MR) were assessed via echocardiography and ventriculography. Intention-to-treat approach was applied for the statistical analysis., Results: Baseline characteristics were not different between the groups. The mean of the estimated balloon reference sizes was significantly higher in the HBRS patients than in the EBRS group (26.4 ± 0.92 mm, 95% confidence interval [CI]: 26.2-26.6 vs 24.5 ± 1.03 mm, 95% CI: 24.2-24.7, respectively; P = 0.006). Final MVAs were significantly larger in the EBRS group (1.5 ± 0.2 cm(2), 95% CI: 1.46-1.59 vs 1.4 ± 0.2 cm(2), 95% CI: 1.35-1.47, respectively; P = 0.01). The occurrence of new or aggravated MR was significantly lower in the EBRS group as assessed both by echocardiography (P = 0.04) and ventriculography (P = 0.05). Mitral regurgitation was aggravated in 13 (29.3%) patients in the HBRS group and in 5 (11.5%) patients in the EBRS group., Conclusions: Percutaneous balloon mitral valvuloplasty via the Inoue technique using balloons sized by the echocardiographic measurement of the maximal commissural diameter is an effective and safe method that might lead to an acceptable increase in the MVA and significant decrease in the rate and severity of iatrogenic MR., (© 2012 Wiley Periodicals, Inc.)

Background: Considerable variations in the development stage among patients of the same chronological age have led to introduce the concept of the developmental age based on the maturation of different organs such as cervical vertebrae or teeth., Objectives: The purpose of this study was to investigate the correlation between the stages of tooth calcification and the cervical vertebral maturation in Iranian females., Patients and Methods: Four hundred females (age range, 8 to 14 years) participated in the study. To determine the dental maturational stage, calcification of the mandibular teeth except for third molars were rated according to the method suggested by Demirjian et al. To evaluate the stage of skeletal maturation, cervical vertebral morphologic changes were assessed on lateral cephalometric radiographs according to the method explained by Baccetti et al. Correlations between bone maturation and teeth calcification were showed by Spearman's correlation and Kendall's tau-b coefficients. The relevant associations were investigated by ordinal logistic regression models., Results: Correlations between the two stages were observed in the first and second premolars, canine and central incisors. All these correlations were significant. The association between cervical vertebral maturation and tooth calcification was greatest in the lateral incisor (odds ratio (OR) = 11, 95% confidence interval (CI): 6.6-18.3). However, considering the 95% CI for OR, no significant difference was detected among the second molar, first molar and lateral incisor., Conclusion: The relationship between calcification of teeth and maturation of cervical bones was significant. Bone maturation can be predicted by using teeth calcification stages, especially in the second molar, first molar and lateral incisor.

Background: In its Constitution of 1948, WHO defined health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity" . In 1994, the Agency for Health Care Policy and Research published clinical practice guidelines recommending providers to routinely evaluate patients' HRQoL (Health Related Quality of Life) and use their assessment to modify and guide patient care., Objectives: to create a valid, sensitive, disease-specific Persian health status quality of life questionnaire for patients with chronic heart failure in Iran., Materials and Methods: Considering the existing relevant inventories and scientific literature, the authors designed the first draft of questionnaire which was modified and validated, using expert opinions and finalized in a session of expert panel. The questionnaire was processed among 130 patients with heart failure. Construct validity evaluated by principle component factor analysis, and promax method was used for factor rotation. MacNew quality of life questionnaire was selected to assess convergence validity, and the agreements were measured in 60 patients. Discriminant validity was also assessed. Thirty patients were followed for 3 months and responsiveness of questionnaire was measured. Cronbach's alpha, item analysis, and Intra-class correlation coefficients (ICCs) were used to investigate reliability of questionnaire. SPSS 15 for Windows was applied for statistical analysis., Results: Principle component factor analysis revealed 4 main components. Sub-group analysis suggested that IHF-QoL questionnaire demonstrated an acceptable discriminant validity. High conformity between this inventory and MacNew questionnaire revealed an appropriate convergence validity. Cronbach's alpha (α) for the overall questionnaire was equal to 0.922. Intra-class correlation coefficients (ICCs) for all components were significant (from. 708 to. 883; all P values < 0.001). Patients fallow-up revealed an acceptable responsiveness of our questionnaire., Conclusions: IHF-QoL questionnaire is a valid and reliable inventory. It can be applied in daily clinical practice and in the clinical research context.

Objectives: Major depressive disorder (MDD) is an increasingly recognized risk factor of coronary artery disease (CAD). The aim of this study was to assess the relationship between renin-angiotensin system (RAS) genetic polymorphisms and CAD in a sample of depressed Iranian patients., Design and Methods: A total of 191 patients with a history of unipolar depression were enrolled in a case/control study. The presence of MDD was reconfirmed at study entry using DSM-IV criteria and CAD was diagnosed by coronary angiography. Genotyping of six RAS genes polymorphisms was performed by a modified PCR-RFLP method., Results: DD genotype of ACE I/D was independently associated with the incidence of CAD in depressed patients (P=0.011, OR=9.41, 95% CI: 1.68-17.81). Moreover, serum creatinine (P=0.033, OR=11.91, 95%CI: 7.23-15.62) was an independent predictor of CAD among depressed individuals., Conclusion: ACE I/D polymorphism may play a major role in the development of CAD amongst Iranian depressed patients., (Copyright © 2012 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Background: Valvular heart diseases and mainly rheumatic heart diseases complicate about 1% of pregnancies. During pregnancy physiological hemodynamic changes of the circulation are the main cause of mitral stenosis (MS) decompensation. Prior to introduction of percutaneous mitral balloon commissuroplasty (PTMC), surgical comissurotomy was the preferred method of treatment in patients with refractory symptoms. PTMC is an established non-surgical treatment of rheumatic mitral stenosis. The study aimed to assess the safety and efficacy of PTMC in pregnant women with severs mitral stenosis., Material and Method: Thirty three consecutive patients undergoing PTMC during pregnancy enrolled in this prospective study. Mitral valve area (MVA), transmitral valve gradient (MVG), and severity of mitral regurgitation (MR) were assessed before and 24 hour after the procedure by transthoracic and transesophageal echocardiography. Mitral valve morphology was evaluated before the procedure using Wilkin's criteria. Patient followed for one month and neonates monitored for weight and height and adverse effect of radiation., Result: Mitral valve area increased from 0.83 ± 0.13 cm(2) to 1.38 ± 0.29 cm(2) (P = 0.007). Mean gradient of mitral valve decreased from 15.5 ± 7.4 mmHg to 2.3 ± 2.3 mmHg (P = <0.001). Pulmonary artery pressure decreased from 65.24 ± 17.9 to 50.45 ± 15.33 (P = 0.012). No maternal death, abortion, intrauterine growth restriction was observed and only one stillbirth occurred., Conclusion: PTMC in pregnant women has favorable outcome and no harmful effect on children noted.