Predicting outcomes in patients with low ejection fraction undergoing coronary artery bypass graft.

Introduction: Reduced left ventricular ejection fraction (LVEF) is a well-known predictor of adverse events after cardiac surgery. We aimed to assess the outcomes in patients with low LVEF undergoing coronary artery bypass graft. Methods: In this retrospective cohort, we included all patients with left ventricular ejection fraction ≤ 40 who underwent coronary artery bypass grafting between March 2007 and March 2016 (with a median follow-up of nine years) at Tehran Heart Center. Demographics and clinical characteristics were extracted from the data registry. Akaike information criterion (AIC) was used. The univariate Cox regression was performed. We investigated the predictors of mortality and major adverse cardiac and cerebrovascular events (MACCE) using Cox multivariable regression. Results: In total, 5,532 cases (79 % male) with a mean age of 65.58 were included in the study. The nine-year overall survival was calculated at 68 %, and more than half of the patients had MACCE (55 %). In adjusted multivariable Cox regression analysis, moderate to severe mitral valve regurgitation, glomerular filtration rate ≤ 60, mild right ventricular dysfunction, and valvular heart disease independently predicted higher mortality. The abovementioned predictors and peripheral vascular disease significantly increased MACCE. Conclusion: Our study indicates the clinical significance of mitral regurgitation, valvular heart disease, and renal function in patients with low ejection fraction treated by coronary artery bypass grafting surgery. Identifying predictors of adverse events can help with clinical decision-making and risk stratification, ultimately improving patient outcomes.

Developing a Risk Prediction Model for Early Atrial Fibrillation Recurrence After Maze Procedure.

BACKGROUND: The efficiency of maze is a safe procedure in AF patients who underwent concomitant mitral valve surgery was more than 60%. The aim of this study was to define predictors of early AF recurrence after concomitant maze procedure with valvular surgery. METHODS: In this retrospective study, 234 patients with AF underwent concomitant valvular replacement and maze procedure. Patients were classified into 2 groups of sinus and atrial fibrillation (AF). Baseline characteristics of patients were then compared between 2 groups. RESULTS: Totally, 234 patients were enrolled, 148 of which maintained sinus rhythm during hospitalization. Left atrial diameter and type of valvular surgery were similar in both groups. Age, number of replaced valves, concomitant coronary artery bypass grafting, and history of preoperative persistent AF and beta-blocker therapy were independent predictors of in-hospital AF recurrence. We used these variables to build a model to anticipate early AF recurrence. CONCLUSIONS: Being older, multivalvular surgery, and persistent preoperative AF were the predictors of higher risk of early recurrent AF, whereas concomitant coronary artery bypass grafting and using beta-blocker had a protective effect. This model based on preoperative and operative characteristics can help us to better evaluate if the patient benefits from maze procedure coincide with valvular surgery.

Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG). METHODS: Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values. RESULTS: Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF. CONCLUSIONS: Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.

Mid to Long-Term Echocardiographic Follow-up of Patients Undergoing Transcatheter Tricuspid Valve-in-Valve Replacement for Degenerated Bioprosthetic Valves: First Single-Center Report from Iran.

Background: Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran. Methods: Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17±1.75 years. Results: All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25±2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08±1.98 mm Hg to 5.29±1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00±49.46 ms to 158.64±57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91±7.31 mm Hg to 26.72±8.99 mm Hg, and left ventricular ejection fraction increased from 47.71±4.70% to 49.79±4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up. Conclusion: This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results.

Safety of thrombolytic therapy in patients with prosthetic heart valve thrombosis who have high international normalized ratio levels.

BACKGROUND AND AIM: Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication of heart valve replacement. Based on the current guidelines, the treatment of a large number of these patients could be performed through the administration of thrombolytic agents. In the present study, we aim to assess the safety of thrombolytic therapy in patients with PVT who have high international normalized ratio (INR) levels. METHODS: In this study, we retrospectively analyzed outcomes of thrombolytic therapy in 65 PVT patients with different levels of INR at the time of fibrinolysis at a tertiary cardiac center. RESULTS: Mean age of patients was 51.6 ± 12.47 years. The tricuspid valve was the most common site of prosthetic valve thrombosis (64.6%). The Median (range) of INR was 2.1 (0.9-4.9). The majority of patients (50.8%) achieved a complete response following thrombolytic treatment. There were no cases of intracranial hemorrhage. Other major and minor bleedings occurred in 3 (4.6%) and 10 (15.4%) patients, respectively. No embolic stroke and systemic embolism were observed. We found no significant difference in the frequency of major (P-value = .809) and minor (P-value = .483) bleeding as well as response to thrombolytic therapy (P-value = .658) between patients with different levels of INR. Total administered dose of Streptokinase was also similar in PVT patients with or without major (P-value = .467) and minor (P-value = .221) bleeding complications. CONCLUSIONS: We concluded that there was no significant difference between PVT patients presenting with subtherapeutic and high INR levels who received thrombolytic treatments regarding both minor and major bleeding complications as well as response to thrombolysis.

Left Atrial Size; a Missing Component in Scoring Systems for Predicting Atrial Fibrillation Following Coronary Artery Bypass Surgery.

BACKGROUND: Several risk factors have been associated with the development of postoperative atrial fibrillation (AF). However, some important factors that may play substantial roles have been neglected in the final suggested risk models. In this study, we aimed to derive a new clinical risk index to predict AF in coronary artery bypass graft (CABG) patients. METHODS: In this retrospective cohort study we enrolled 3047 isolated CABG patients. A random sample of 2032 patients was used to derive a risk index for the prediction of post-CABG AF. A multivariate logistic regression model identified the independent preoperative predictors of post-CABG AF, and a simple risk index to predict AF was constructed. This risk index was cross-validated in a validation set of 1015 patients with isolated CABG. RESULTS: Post-CABG AF occurred in 15.9% and 15.7% of the patients in the prediction and validation sets, respectively. Using multivariate stepwise analysis, four preoperative variables including advanced age, left atrial (LA) enlargement, hypertension and cerebrovascular accident contributed to the prediction model (area under the receiver operating characteristic curve curve = 0.66). The effect of advanced age appeared to be dominant [age ≥ 75 years; odds ratio: 4.134, 95% confidence interval (CI): 2.791-6.121, p < 0.001]. Moderate to severe LA enlargement had an odds ratio of 2.176 (95% CI: 1.240-3.820, p = 0.013) for developing AF in our risk index. CONCLUSIONS: LA size was an important factor in risk stratification of post-CABG AF, which remained significant in the final model. Future scoring system studies might benefit from the use of this variable to obtain a more robust predictive value.

Endovascular Repair of a Common Carotid Pseudoaneurysm in a Patient with Behçet's Disease: A Case Report and Review of Literature.

Behçet's disease (BD) is a multisystem inflammatory disorder. Physicians should be alerted to the possibility of BD in a patient with a carotid artery pseudoaneurysm and no clear predisposing factor such as neck trauma or surgery. Endovascular repair of carotid pseudoaneurysms is technically feasible with excellent midterm follow-up results. Administration of immunosuppressive therapy before endovascular intervention is mandatory to reduce the chance of vascular complications accompanied by BD. A 40-year-old man presented with a painful and pulsatile neck mass with 2 episodes of transient ischemic attacks. The patient also complained of recurrent urogenital ulcers and aphthous lesions together with painful rashes. Ultrasonography and computed tomography angiography revealed 2 aneurysmal dilations in the left common carotid artery at the bifurcation level. He was referred to a rheumatologist, who made the diagnosis of BD. High-dose corticosteroids and cyclophosphamide were commenced. One week later, 2 overlapping self-expanding stent grafts were deployed. The final angiogram showed no residual endoleak, and the flow of the carotid and cerebral arteries was satisfactory. The patient was discharged with no neurological complications. Follow-up ultrasonography and computed tomography angiography 6 months later showed no endoleak, as well as significant shrinkage of the aneurysm sac.

Fenestrated Endovascular Aortic Aneurysm Repair (FEVAR) for Complex Thoracoabdominal and Abdominal Aortic Aneurysms: First Iranian FEVAR Series Report with Mid-Term Follow-Up.

Endovascular treatment of aortic diseases has improved in recent years. More complex thoracoabdominal and juxtarenal abdominal aortic aneurysms can now be treated with new stent grafts and techniques. Fenestrated endovascular aortic aneurysm repair (FEVAR) with fenestrated stent grafts was commenced in our center after hundred cases of endovascular aortic repair, and so far 4 serial complex cases deemed inoperable (2 juxtarenal abdominal aortic aneurysms, 1 thoracoabdominal aneurysm, and 1 thoracoabdominal pseudoaneurysm) have been treated with FEVAR. All these patients needed custom-made stent grafts, which were designed and implanted successfully under general anesthesia in the catheterization laboratory. They were followed up for more than 1 year, with a median follow-up period of 23.0 months. There were no major in-hospital or short-term complications. Only 1 patient had midterm unilateral iliac artery thrombosis, which was successfully managed interventionally. Computed tomography angiography at 1 year's follow-up showed that the stent grafts were patent and their visceral branch cover stents had no endoleak.

Transcatheter heart valve in valve implantation with Edwards SAPIEN bioprosthetic valve for different degenerated bioprosthetic valve positions (First Iranian ViV report with mid-term follow up).

Introduction: After early successful experience with transcatheter aortic valve replacement (TAVR), concept of transcatheter implantation of a new valve within a failing bioprosthetic valve emerged. Valve-in-valve (ViV) implantation seems to be a simpler option for high risk surgical patients. Methods: We performed five ViV procedures in different valve positions. We included patients with failing bioprosthetic valves with high surgical risk due to concomitant comorbidities. We performed 2 transapical ViV procedures for failing mitral bioprosthetic valves, 1 transfemoral procedure for failing pulmonary valve and 2 transfemoral ViV implantation for failing tricuspid bioprosthetic valves. Results: The procedures were successfully completed in all 5 cases with initial excellent fluoroscopic and echocardiographic verification. There was no valve embolization or paravalvular leakage in any of the cases. Transcatheter valve function was appropriate with echocardiography. Post procedural clinical adverse events like pleural effusion and transient ischemic attack were managed successfully. In midterm follow up all cases remained in appropriate functional class except from the transcatheter pulmonary valve which became moderately stenotic and regurgitant. Conclusion: As the first Iranian all-comers case series with midterm follow up for ViV implantation, we had no mortality. Interestingly none of our patients had neurologic sequelae after the procedure. Midterm follow up for our patients was acceptable with good functional class and appropriate echocardiographic findings. Due to high surgical risk of the redo procedure after failing of a bioprosthetic valve especially in elderly patients with comorbidities, ViV implantation would be a good alternative to surgery for this high risk group.

Ruptured Sinus of Valsalva Aneurysm Accompanied by Aortic and Tricuspid Valve Endocarditis: A Case Report.

A ruptured sinus of Valsalva aneurysm rarely accompanies the aortic and tricuspid valve endocarditis. A 36-year-old woman presented with low-threshold dyspnea on exertion and fever. Transthoracic and transesophageal echocardiography showed a ruptured noncoronary sinus of Valsalva aneurysm with large vegetations on the tricuspid and aortic valves, resulting in moderately severe tricuspid regurgitation and severe aortic regurgitation. Blood culture was negative. The patient was initially treated with antibiotics and then subjected to the surgical repair of the sinus of Valsalva aneurysm and the tricuspid and aortic valve replacement. The patient's postoperative period was uneventful, and she was discharged healthy.

Hopelessness among adults with congenital heart disease: Cause for despair or hope?

BACKGROUND: Adults with congenital heart disease (CHD) face unique life courses and challenges that may negatively influence their psychological functioning. The aims of this study were to (1) examine the level of hopelessness among adults with CHD in comparison with non-CHD participants and (2) identify correlates of elevated hopelessness among adults with CHD. METHODS: We enrolled 347 patients with CHD (18-64years, 52.2% female) and 353 matched (by sex/age) non-CHD persons in this cross-sectional study. Hopelessness was assessed by Beck Hopelessness Scale. Hierarchical multiple logistic regression analyses were performed to explore correlates of elevated hopelessness. RESULTS: The mean total hopelessness score did not significantly differ between the CHD and non-CHD groups. Twenty-eight percent of CHD patients had elevated hopelessness scores. Within the CHD patient sample, regression analyses revealed that being male (odds ratio=2.62), not having children (odds ratio=3.57), being unemployed (odds ratio=2.27), and elevated depressive symptoms (odds ratio=1.21) were significantly associated with hopelessness. Regular physical activity (odds ratio=0.36) emerged as a protective factor and all CHD disease parameters were unrelated to hopelessness. The final model explained 43% of the variance in hopelessness. CONCLUSIONS: Adult CHD teams are encouraged to continue to explore strategies to support patients to live as rich and full as lives as possible by pursuing relationships, employment and physical activity, as well as managing depression and hopelessness.

Association between herpes simplex virus Types 1 and 2 with cardiac myxoma.

Most cases of atrial myxoma are sporadic, and the exact etiology is unknown. We examined if herpes simplex virus (HSV)-1 and HSV-2 antigens and/or DNA could be detected in a cohort of Iranian patients with cardiac myxomas. From July 2004 to June 2014, among a total of 36,703 patients undergoing open heart surgeries, consecutive patients with cardiac myxoma who were treated by surgical excision at our center included in this study. Of 73 patients studied, 56% were female with a mean age of 54 years (ranging from 23 to 77 years). Seventy-four myxomas were surgically removed from 73 patients, since one patient had two myxomas which were located on both the right atrium and right ventricle. The materials for this analysis were retrospectively gathered from extracted tumors that stored in a pathology bank of tissue paraffin blocks. The formalin fixed paraffin embedded tissue samples were investigated for HSV genomic DNA by both immunohistochemistry (IHC) and polymerase chain reaction (PCR) analysis. In all 74 cases there was no presence of HSV 1 and HSV 2 infection. This suggests that HSV may not play a role in sporadic cardiac myxomas; however, evidence for such association is currently lacking, and further studies are required to determine such a role.

Takayasu's Arteritis Presenting with Headache and Peripheral Facial Palsy: A Case Report.

Takayasu's arteritis (TA) is a rare case of granulomatous arteritis which mainly involves the aorta and its large branches. Although arterial hypertension is the most common feature of the disease in both adults and children, patients with TA may present with numerous clinical manifestations. Our patient was a 45-year-old woman, known to have hypertension from 3 years earlier following assessments made for severe headache. One year after the diagnosis of hypertension, she developed a left-sided lower motor neuron facial palsy, which was treated with oral corticosteroids (Prednisolone). Notably, the patient's headache was relieved after she took corticosteroid therapy. Transthoracic echocardiography revealed severe aortic insufficiency and aneurysmal changes in the ascending aorta, and she was referred to our center for further evaluation. In multi-slice computed-tomography angiography, significant long stenosis of the left subclavian artery was seen and the diameter of the ascending aorta was 50 mm. The patient underwent the Bentall operation. The pathologic examination of the aortic wall specimen was compatible with giant cell aortitis and more in favor of TA with the ascending aortic aneurysm. At 6months' follow-up, the patient was in good condition and had almost recovered from facial palsy.

Preoperative oral pentoxifylline in case of coronary artery bypass grafting with left ventricular dysfunction (ejection fraction equal to/less than 30%).

OBJECTIVE: Most coronary artery bypass grafts are done by applying cardiopulmonary bypass, which usually induces unwanted inflammatory reactions and impairs the outcomes. In order to minimize the perilous response of cardiopulmonary bypass, pentoxifylline was getting used orally. METHODS: In a prospective, placebo-controlled, randomized clinical trial, 178 coronary artery bypass graft candidates with ejection fraction lower/equal to 30%, divided into two equal groups (pentoxifylline and control), participated in the study. Pentoxifylline patients received 400 mg pentoxifylline 3 times a day for 3 days before operation. The outcomes were compared between groups using student's t-test, Mann-Whitney U-test, Pearson chi-square, or Fisher's exact test. RESULTS: Pentoxifylline administration did not significantly affect troponin-T (p=0.68), but it reduced tumor necrosis factor-α (p=0.01) and interleukin-6 (p=0.01). It improved left ventricular ejection fraction significantly (p=0.01). White blood cell and platelet counts, hemoglobin, and hematocrit were not influenced by pentoxifylline. The drug did not affect blood urea nitrogen and creatinine, occurrence of renal failure, cerebrovascular accidents, and in-hospital mortality rate. The need for an intra-aortic balloon pump, cardiopulmonary bypass, and aortic cross-clamp times were not affected, either. Pentoxifylline decreased the intensive care unit stay (p<0.001), ventilation time, 10.4 hours in the pentoxifylline group against 14.7 hours in the control group (p=0.01), and the requirement of inotropic agents (p=0.02) and blood transfusion (p=0.01). CONCLUSION: Pentoxifylline has more beneficial potencies in reducing adverse events after coronary artery bypass graft using cardiopulmonary bypass, than what are known.

Early outcome of off-pump versus on-pump coronary revascularization.

INTRODUCTION: The use of coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) or without CPB technique (off-pump) can be associated with different mortality and morbidity and their outcomes remain uncertain. The goal of this study was to evaluate the early outcome of on-pump versus off-pump CABG. METHODS: We conducted a retrospective database review of 13866 patients (13560 patients undergoing on-pump CABG and 306 patients undergoing off-pump CABG) at Tehran Heart Center between January 2002 and January 2007. We compared preoperative, operative, and postoperative characteristics between them. RESULTS: In-hospital mortality in the on-pump group was 0.8% compared to 0.7% in the off-pump group (P=0.999) and in-hospital morbidity was 11.7% and 6.5%, respectively (OR: 1.533, 95%CI: 0.902-2.605, P=0.114). Postoperative atrial fibrillation was more prevalent in on-pump versus off-pump surgery (6.0% vs 3.0%, P=0.028), however there were no statistical significant differences in other postoperative complications with regard to cardiac arrest (P=0.733), prolonged ventilation (P=0.363), brain stroke (P=0.999), renal failure (P=0.525), and postoperative bleeding (P=0.999). The mean length of stay in hospital (P=0.156) and in ICU (P=0.498) was also similar between the two groups. CONCLUSION: The results from an Iranian population-based study showed similar early mortality and morbidity of off-pump CABG in comparison to on-pump surgery.

Clinicopathologic review of non-myxoma cardiac tumors: a 10-year single-center experience.

OBJECTIVE: To report the prevalence, clinical presentation and histological characteristics of non-myxoma cardiac tumors in a major tertiary heart center. METHOD: Review of the medical profiles of 36,930 patients admitted to our hospital between 2003 and 2013 yielded a total of 86 cases of cardiac tumors (63 cases of myxomas and 23 cases of non-myxoma tumors). Clinical presentations and histological features were presented exclusively for primary and secondary tumors. RESULTS: Of 23 enrolled patients with non-myxoma tumors, 5 had primary tumors and 18 had secondary or metastatic tumors. The most frequent origins of the secondary tumors were breast cancer, lymphoma, leukemia and lung cancer. Most secondary tumors had pericardial involvement, and only one tumor involved the left atrium. Sarcomas, including spindle-cell sarcoma and liposarcoma, comprised the majority of the primary malignant tumors. None of these tumors had pericardial involvement, and, except for one case, all were confined to the left side of the heart. All patients were symptomatic on admission, with dyspnea being the most frequent presenting symptom. CONCLUSION: Metastatic cardiac tumors were more prevalent than the primary ones, with fibromas constituting the largest proportion of the primary tumors and breast cancer being the prevalent cause of metastasis.

Immediate Postoperative Complications in Patients Undergoing CABG; Investigating the Role of Prior Coronary Stenting.

INTRODUCTION: Approximately 15 to 30% of patients undergoing percutaneous coronary intervention (PCI) will require repeated revascularization. There is an ongoing debate concerning the impact of prior PCI on subsequent coronary artery bypass graft (CABG) surgery. This study sought to compare immediate post-CABG complications between patients with and without previous coronary stenting. METHODS: A total of 556 CABG candidates including 73 patients with previous coronary stenting and 483 patients without prior stenting were enrolled in this retrospective-prospective study. Demographic information, cardiac markers (CK-MB, Troponin T), and postoperative data including inotrope administration, intra-aortic balloon pump (IABP) use, bleeding, pathological electrocardiography (ECG) changes, and overall complications were compared between the two groups. RESULTS: The mean age of the patients in stented group was significantly higher than that in unstented group (63.49±7.71 vs. 61.37±9.80 years, p=0.05). The mean serum level of Troponin T 12 h postoperation was significantly higher in the same group (323.26±33.16 vs. 243.30±11.52 ng/dL; p=0.03). Comparing the stented and unstented groups, the rates of inotrope use (17.8% vs. 7.2%; p=0.003), significant bleeding (15.1% vs. 4.3%; p=0.001), and overall complications (32.9% vs. 11.6%; odds ratio: 3.74 with 95% confidence interval of 2.13-6.55, p<0.001) were significantly higher in the former group. The association between overall complications and prior stenting was independent (odd ratio: 3.06). No significant connections were found between postoperative complications and stent number or type. CONCLUSION: A positive history of previous coronary stenting significantly increases the risk of immediate post-CABG complications.