Evaluating the efficacy and safety of rivaroxaban as a warfarin alternative in chronic thromboembolic pulmonary hypertension patients undergoing pulmonary endarterectomy: A randomized clinical trial.

BACKGROUND AND AIM: Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by the obstruction of the main pulmonary artery due to thrombosis and vascular remodeling. Regarding the need for anticoagulant therapy in CTEPH patients, this study aimed to compare rivaroxaban with warfarin in terms of its efficacy and safety in patients undergoing endarterectomy surgery. METHODS: The study was a parallel clinical trial in patients who underwent endarterectomy following CTEPH. A total of 96 patients were randomly selected and assigned to two groups: warfarin-treated (control) and rivaroxaban-treated (intervention). Patients were clinically assessed for re-thrombosis, re-admission, bleeding, and mortality in the first, third, and sixth months after surgery. RESULTS: There was no significant difference in the occurrence of thrombosis between the two groups within the first, third-, and sixth-months post-surgery (p=0.52, 1, 0.38 respectively). Moreover, the mortality rate (p=0.9), bleeding rate (p=0.06), and re-admission rate (p=0.15) showed no significant differences between the two groups. CONCLUSION: Rivaroxaban may be as effective as warfarin in treating CTEPH patients after endarterectomy in the short term and can be used as an anticoagulant in these patients. However, studies with long-term follow-ups are needed to consolidate the strategy of treating these patients with rivaroxaban.

Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients.

OBJECTIVES: Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. MATERIALS AND METHODS: Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. RESULTS: Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). CONCLUSIONS: Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.

Early post-operative acute kidney injury after cardiac transplantation: Incidence and predictive factors.

BACKGROUND: Heart transplantation, as a therapeutic option for patients with advanced heart failure, possesses a high rate of morbidity and mortality. One of the complications associated with this procedure is the development of postoperative acute kidney injury (AKI) MATERIAL AND METHODS: We aimed to evaluate the incidence of early postoperative AKI and the need for continuous renal replacement therapy (RRT) after heart transplantation. Data of 126 patients who underwent heart transplantation from January 2015 to November 2019 were collected. Statistical analysis was performed to identify the predictors of postoperative AKI. RESULTS: Out of 126 patients, 74 (58.7 %) developed AKI and 13 (10%) required RRT after transplant. Independent predictors of AKI are shown to be factors associated with surgical procedures such as graft ischemic time as were previous cardiac operation, administered Voluven (starch) dose > 400 ml, and transfusion of more than four blood units. CONCLUSION: Our findings suggest that modifiable factors exist that can affect the risk of developing AKI following heart transplantation.

Evaluation of cardiomyopathy diagnosis in heart transplant recipients: comparison of echocardiographic and pathologic classification.

BACKGROUND: Definite diagnosis of cardiomyopathy types can be challenging in end-stage disease process. New growing data have suggested that there is inconsistency between echocardiography and pathology in defining type of cardiomyopathy before and after heart transplantation. The aim of the present study was to compare the pre-heart transplant echocardiographic diagnosis of cardiomyopathy with the results of post-transplant pathologic diagnosis. RESULTS: In this retrospective cross-sectional clinicopathological study, 100 consecutive patients have undergone heart transplantation in Masih-Daneshvari hospital, Tehran, Iran, between 2010 and 2019. The mean age of patients was 40 ± 13 years and 79% of patients were male. The frequency of different types of cardiomyopathy was significantly different between two diagnostic tools (echocardiography versus pathology, P < 0.001). On the other hand, in 24 patients, the results of echocardiography as regard to the type of cardiomyopathy were inconsistent with pathologic findings. CONCLUSION: Based on the findings of the present study, it could be concluded that there is a significant difference between echocardiographic and pathologic diagnosis of cardiomyopathy; therefore, it is necessary to use additional tools for definite diagnosis of cardiomyopathy like advanced cardiac imaging or even endomyocardial biopsy before heart transplantation to reach an appropriate treatment strategy.

Superior vena cava obstruction and pulmonary artery involvement as rare findings of immunoglobulin G4-related disease.

We describe a case of immunoglobulin G4-related lung disease presenting as chronic pulmonary hypertension with involvement of right pulmonary artery and superior vena cava. Immunoglobulin G4- related disease is a rare systemic sclerosing disease with autoimmune entity that causes fibrotic, often mass-like manifestations that variably affect different organ systems and can be mistaken with other disorders. Timely diagnosis requires awareness on the part of clinicians and pathologists as well as radiologists to the variable manifestations of this newly recognized disorder. .

Clinical Manifestations of Patients with Coronavirus Disease 2019 (COVID-19) in a Referral Center in Iran.

BACKGROUND: Following the recent epidemic of coronavirus disease 2019 (COVID-19) in Wuhan, China, a novel betacoronavirus was isolated from two patients in Iran on February 19, 2020. In this study, we aimed to determine the clinical manifestations and outcomes of the first confirmed cases of COVID-19 infection (n=127). MATERIALS AND METHODS: This prospective study was conducted on all COVID-19-suspected cases, admitted to Masih Daneshvari Hospital (a designated hospital for COVID-19), Tehran, Iran, since February 19, 2020. All patients were tested for COVID-19, using reverse transcription-polymerase chain reaction (RT-PCR) assay. Data of confirmed cases, including demographic characteristics, clinical features, and outcomes, were collected and compared between three groups of patients, requiring different types of admission (requiring ICU admission, admission to the general ward, and transfer to ICU). RESULTS: Of 412 suspected cases, with the mean age of 54.1 years (SD=13.4), 127 (31%) were positive for COVID-19. Following the patients' first visit to the clinic, 115 cases were admitted to the general ward, while ten patients required ICU admission. Due to clinical deterioration in the condition of 25 patients (out of 115 patients), ICU admission was essential. Based on the results, the baseline characteristics of the groups were similar. Patients requiring ICU admission were more likely to have multiorgan involvement (liver involvement, P<0.001; renal involvement, P<0.001; and cardiac involvement, P=0.02), low O2 saturation (P<0.001), and lymphopenia (P=0.05). During hospital admission, 21 (16.5%) patients died, while the rest (83.5%) were discharged and followed-up until March 26, 2020. Also, the survival rate of patients, who received immunoglobulin, was higher than other patients (60.87% vs. 39.13%). CONCLUSION: The mortality rate of COVID-19 patients was considerable in our study. Based on the present results, this infection can cause multiorgan damage. Therefore, intensive monitoring of these patients needs to be considered.

Iranian Society of Cardiac Surgeons COVID-19 task force version II, restarting elective surgeries.

Given the nature of heart disease and the importance of continuing heart surgery during the pandemic and its aftermath and in order to provide adequate safety for the surgical team and achieve the desired result for patients, as well as the optimal use of ICU beds, the medical team, blood, blood products, and personal protective equipment, it is essential to change the usual approach during the pandemic. There are still a lot of evidences and experiences needed to produce the perfect protocol. Some centers may have a special program for their centers during this period of epidemics that can be respected and performed. Generally, in pandemic conditions, the use of non-surgical approaches is preferred if similar outcomes can be obtained.

Extracorporeal membrane oxygenation and COVID-19: The causes of failure.

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV-ECMO failure are not yet understood well. CASE SERIES: Here, seven patients with COVID-19-induced ARDS who underwent VV-ECMO introduced and causes of VV-ECMO failure discussed. Medical records of seven COVID-19 patients treated with VV-ECMO were retrospectively evaluated to determine the clinical outcomes of VV-ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV-ECMO decannulation was done in three patients, however finally one patient survived. CONCLUSIONS: Hypercoagulability state and oxygenator failure were the most main etiologies for VV-ECMO failure in our study. All patients with COVID-19 undergoing VV-ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV-ECMO.

Removing an Entrapped Pigtail Catheter by Re-enforcing a Traditional Method.

Right heart catheterization is the main step in the evaluation of pulmonary hypertension including Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and is considered a relatively safe procedure. Complications can occur including perforation, tamponade, bleeding, etc. requiring different types of interventions such as manipulation or surgery. Here, we have described a case of pigtail catheter entrapment and the method we used to free it without invasive measures.

ECMO-assisted resection of huge thoracic mass.

Some advanced thoracic malignancy cannot be resected safely by using of conventional ventilation, so some sort of cardiopulmonary support is needed for hemodynamic and ventilation management of the patient. Using extracorporeal membrane oxygenation (ECMO) in comparing with cardiopulmonary bypass has some advantages. Three patients with huge thoracic tumors with different ages experienced major surgery in our center by using ECMO in order to face major complications mainly due to the size of mass to achieve better hemostatic stabilities, lower bleeding, and injuries to main airways and secure oxygenation. This is the first case series in Iran, as our best knowledge that explains cases of huge chest mass which were operated perfectly by using ECMO and short ICU stay and interestingly no major complications.

Traumatic Transection of Descending Thoracic Aorta Presenting as Pseudo- Coarctation.

Background: Thoracic Aortic Injury (TAI) due to penetrating or blunt chest trauma is a critical life-threatening aortic injury. Its diagnosis and treatment always is challenging. An 18-year-old male was admitted due to blunt chest trauma after a high-impact road traffic collision. According to presenting dyspnea, an emergency chest-x-ray revealed left hemothorax for which chest tube was inserted. Hemodynamic monitoring demonstrated uncontrolled hypertension with systolic blood pressure of 200-220 mmHg despite multiple anti-hypertensive drugs. Trans-Thoracic Echocardiography (TTE) revealed abnormal Doppler flow pattern in proximal descending thoracic aorta suggestive for probable coarctation of aorta. Chest CT scan revealed pseudoaneurysm of the descending thoracic aorta just below the isthmus. Due to uncontrolled hypertension, persistent hemothorax and probable aortic pseudoaneurysm presenting as aortic luminal narrowing, surgical resection of the aneurysm was planned. The postoperative course was uneventful and blood pressure normalized without any drugs. Patient is normotensive after 8 years follow up.

First Experience with Extracorporeal Membrane Oxygenation in Iran, under Difficult Conditions.

Background: Extracorporeal membrane oxygenation (ECMO) provides hemodynamic and oxygenation support in critical conditions. The commencement of this modality in Iran coincided with severe economic constraints across Iran. Methods: This retrospective study was performed in Masih Daneshvari Medical Center from 2010 to 2015, during which period, sanction-related limitations in the import of equipment prompted us to integrate a Medtronic or Stöckert head pump console into a Maquet ECMO Oxygenator so as to sustain the ECMO program. Comparisons were performed between successful and unsuccessful ECMO procedures and survivors. Factors associated with unsuccessful ECMO were evaluated with a multivariate logistic regression. Results: Thirty-three (68.8%) patients were male and 15 (31.2%) were female. The mean age of the patients was 35±16.6 years. Thirty-seven (77.1%) patients were weaned off ECMO successfully; the rate was higher than that in previous studies. Totally, 35.4% of the study population survived to hospital discharge. The most common cause of death in all the ECMO patients who were successfully weaned was sepsis. The most common cause of death in the patients who underwent unsuccessful ECMO was multisystem organ failure. The mean ECMO support time was 53.37±46.26 hours. The patients who were alive at discharge were significantly younger (25.5±14.5 vs. 40.2±15.5 y; P=0.002) and had a significantly lower ECMO duration (24 [25-75% interquartile: 18.5-36] vs. 48 [25-75% interquartile: 24-72] h; P=0.044) than the non-survivors. Conclusion: An assembly of ECMO components from different companies could be done safely, at least for a short period of time.

Prophylactic Fibrinogen Decreases Postoperative Bleeding but Not Acute Kidney Injury in Patients Undergoing Heart Transplantation.

The present study is the premier clinical attempt to scrutinize the practicability of prophylactic fibrinogen infusion in patients undergoing heart transplantation (HT). A total of 67 consecutive patients who had undergone HT between January 2012 and December 2014 were assessed. After exclusion of some patients, 23 patients were given preoperative 2 g fibrinogen concentrate over a period of 15 minutes after the termination of cardiopulmonary bypass pump and complete reversal of heparin, and 30 patients were not given. Some laboratories were measured before general anesthesia and at 6 and 24 hours after surgery. In addition, major adverse events were also evaluated during hospitalization. The mean age of the patients was 39.5 ± 11.4 years, with a predominance of male sex (77.4%). All laboratories at baseline were comparable between groups. The length of hospital stay was longer in the control group compared to the fibrinogen group (20 [16-22] vs 16 [12-19] days; P = .005). There was a trend for patients in the fibrinogen group to have more acute kidney injury (AKI) after surgery (10% vs 30.4%) and less reoperation for bleeding (20% vs 8.7%). The amount of postoperative bleeding was significantly higher in the control group compared to the fibrinogen group ( P < .001). The number of packed red blood cell transfused during 24 hours after surgery was significantly lower in the fibrinogen group ( P < .001). The transfusion of fibrinogen in patients undergoing HT may be associated with reductions in postoperative bleeding, the number of packed red blood cells, and hospital length of stay; however, it may enhance postoperative AKI.

Asymptomatic Giant Lipoma of the Right Ventricular Outflow Tract: A Case Report.

Cardiac lipomas are extremely rare tumors of the heart. They are usually symptomatic and rarely may be found incidentally in autopsies. Here we describe a 23-year-old healthy man, in whose physical examination for employment a murmur was found incidentally. Transthoracic and then transesophageal echocardiographic examination showed a 4-cm oval-shaped mass in the right ventricular outflow tract. He underwent elective surgery, during which the tumor was removed under cardiopulmonary bypass and aortic-cross clamping via right atriotomy. The postoperative course was uneventful, and the patient was in good condition at 1 year's follow-up.

Right Ventricular Perforation with the Body of Swan-Ganz Catheter during Lung Transplantation by ECMO Support: A Case Report.

A 46-year-old woman with a 12-year history of lymphangiomyomatosis (LAM) was admitted for lung transplantation in January 2017. We decided to apply veno-arterial extracorporeal membrane oxygenation (ECMO) to manage arrhythmia and hypotension during lung transplantation, since it was not controllable with inotropic drugs. After transplanting the right (first) lung and at the time of left pneumonectomy, the body of the Swan-Ganz catheter was suddenly observed to be protruding from the right ventricular (RV) wall. The catheter was found folded at part of its body and ran out 0.5 cm from the RV. The protruding part of the catheter was inserted before the perforated part of the cardiac muscle was repaired in order to control the bleeding. ECMO was used throughout the rest of the procedure and the patient was transferred to the intensive care unit (ICU) in good condition before being weaned from the ventilator after 16 hours. It seems that gentle manipulation, concurrent use of transesophageal echocardiography (TEE), insertion of the appropriate length of the catheter into the heart chambers, and a softer material in the structure of the catheters would be helpful to prevent these kinds of potentially fatal complications.

Superior vena cava obstruction after heart transplantation.

Superior vena cava obstruction can be a serious complication after heart transplantation. A 58-year-old man with ischemic cardiomyopathy underwent orthotopic bicaval heart transplantation. On the 12th postoperative day, one hour after removing the central venous line, he developed sudden onset of facial edema, cyanosis, and tachycardia. Emergency transesophageal echocardiography revealed superior vena caval thrombosis at the site of anastomosis. Considering the risks of surgical reexploration, the superior vena cava was recanalized by stent deployment. All of the patient's symptoms were relieved a few hours after stent placement.

Ultra fast-track extubation in heart transplant surgery patients.

BACKGROUND: Heart transplant surgeries using cardiopulmonary bypass (CPB) typically requires mechanical ventilation in intensive care units (ICU) in post-operation period. Ultra fast-track extubation (UFE) have been described in patients undergoing various cardiac surgeries. AIM: To determine the possibility of ultra-fast-track extubation instead of late extubation in post heart transplant patients. MATERIALS AND METHODS: Patients randomly assigned into two groups; Ultra fast-track extubation (UFE) group was defined by extubation inside operating room right after surgery. Late extubation group was defined by patients who were not extubated in operating room and transferred to post operation cardiac care unit (CCU) to extubate. RESULTS: The mean cardiopulmonary bypass time was 136.8 ± 25.7 minutes in ultra-fast extubation and 145.3 ± 29.8 minutes in late extubation patients (P > 0.05). Mechanical ventilation duration (days) was 0 days in ultra-fast and 2.31 ± 1.8 days in late extubation. Length of ICU stay was significantly higher in late extubation group (4.2 ± 1.2 days) than the UFE group (1.72 ± 1.5 days) (P = 0.02). In survival analysis there was no significant difference between ultra-fast and late extubation groups (Log-rank test, P = 0.9). CONCLUSIONS: Patients undergoing cardiac transplant could be managed with "ultra-fast-track extubation", without increased morbidity and mortality.

Massive hemoptysis, a presentation of invasion of aneurysm of descending aorta to bronchopulmonary tree.

Aortobronchial (AB) fistula is a rare disease, which is presented with massive hemoptysis; lethal if not treated. It should be suspected in any patient who presents with massive hemoptysis and had previous thoracic aortic surgery, but even it may be seen in patients without any history of operation on the thoracic aorta. Although, today in many centers endovascular therapy is done for these patients, but it is not the standard approach. Surgery in urgent situations has an essential role in saving the patients. Operative management consists of double lumen intubation and one lung ventilation, followed by femoral artery and vein cannulation, posterolateral thoracotomy and achieving proximal and distal control on the aorta, applying cardiopulmonary bypass (CPB), separation the lesion, and bypass the segment of the diseased aorta by a synthetic graft.