Serum Levels of miR-155, miR-326, and miR-133b as Early Diagnostic Biomarkers for the Detection of Human Acute Heart Allograft Rejection in Comparison with Serum Cardiac Troponin T.

BACKGROUND: Acute heart allograft rejection occurs as a result of antibody-mediated rejection that presents during the first month after transplantation. Finding a non-invasive biomarker is essential for diagnosis of heart allograft rejection. In this research, we intended to compare expression levels of several microRNAs across cardiac troponin T levels between rejected patients (who died before one month following transplantation), non-rejected patients (who survived for at least one month after transplantation), and non-transplanted patients (CABG surgery patients). METHODS: Serum levels of miR-155, miR-326, and miR-133b were evaluated by the q-RT-PCR method. Furthermore, cardiac troponin T levels were measured by a highly sensitive electrochemiluminescence assay. Finally, the data were analyzed by independent sample t-test using SPSS 21® computer software. Results: It was observed that miR-326 and miR-155 expression levels increased after 24h and 72h of surgery in rejected patients compared with the two other groups, but these increases were not statistically significant. Moreover, the decrease in miR-133b expression level was non-significant after transplantation in the rejected group compared with the non-rejected group. However, cTnT levels in rejected patients increased significantly compared with the other groups (P < .05). After ROC curve analysis, the cTnT marker with the most area under the curve (AUC = 1.00, 95% confidence interval, 1.00 to 1.00; P = .006), had the best discriminatory power, and among microRNAs, miR-326 had the largest area under curve (AUC = 0.81), and consequently the highest discriminatory power. CONCLUSIONS: We demonstrated that troponin T can be a more efficient biomarker than miRNAs for early prediction of human death caused by acute heart rejection, and the ROC curves analysis verified this finding.

Appropriate blood component therapy can reduce postcardiac surgery acute kidney injury through packed cell transfusion reduction.

BACKGROUND: Acute kidney injury (AKI) can happen due to different factors such as anemia. Packed cell (PC) transfusion is an important cause of AKI occurrence. The aim of the study is to investigate whether appropriate blood component (BC) therapy can reduce blood transfusion and it would result in AKI decreasing. MATERIALS AND METHODS: We conducted a cohort study of 1388 patients who underwent cardiac surgery in one university hospital. A serum creatinine higher than 2 mg/dl, renal disease history, renal replacement therapy (chronic dialysis) were our exclusion criteria. RESULTS: From our 1088 samples, 701 (64.43%) patients had normal kidney function, 277 (25.45%) were in the AKI-1 group, 84 (7.72%) had an AKI-2 function, and the rest of patients were classified as end stage. A mean of more than three PC units were transfused for the second and third stage of AKI, which was significantly higher than other AKI groups (P = 0.009); this higher demand of blood product was also true about the fresh frozen plasma, platelet, and fibrinogen. However, there were no needs of fibrinogen in the patients with normal kidney function. The cardiopulmonary bypass time had an average of 142 ± 24.12, which obviously was higher than other groups (P = 0.032). Total mortality rate was 14 out of 1088 (1.28%), and expiration among the AKI stages 2 and 3 was meaningfully (P = 0.001) more than the other groups. CONCLUSION: A more occurrence of AKI reported for the patients who have taken more units of blood. However, BC indicated to be safer for compensating blood loss because of low AKI occurrence among our patients.

Cold Therapy and Respiratory Relaxation Exercise on Pain and Anxiety Related to Chest Tube Removal: A Clinical Trial.

BACKGROUND: Current strategies to control pain and anxiety of chest tube removal are not efficacious. The aim of this study is to determine the effects of cold therapy and respiratory relaxation exercise on pain and anxiety of chest tube removal. MATERIALS AND METHODS: A parallel single-blind clinical trial study was conducted in Imam Khomeini Hospital, Iran, on 120 patients. Participants were randomized into 4 groups of 30. Numeric Rating Scale was used to assess pain and anxiety. One-way ANOVA test and Fisher's exact test were used to analyze demographic data. The Kruskal-Wallis test was used to compare the severity of pain and anxiety between groups; the Friedman and Mann-Whitney test were used to compare the severity of pain and anxiety within groups with a significance level of 0.05. RESULTS: Pain intensity was weak before chest tube removal and there was no significant difference in basal pain. Pain immediately after chest tube removal was significantly higher than other times in each group (χ 2 = 57.16, χ 2 = 63.70, χ2 = 46.49, χ 2 = 59.04, df = 3, p < 0.001). There was no significant difference in pain score immediately (p = 0.052) and 15 min (p = 0.329) after Echest tube removal in experimental groups compared to the control group. No significant difference was found between control and experimental groups in anxiety score immediately (p = 0.995) and 15 min (p = 0.976) before chest tube removal. CONCLUSIONS: Mentioned methods were not effective in reducing pain and anxiety. It is suggested to investigate effects of different methods of removing chest tubes and applying cold with a larger sample size.

Association between Illness Perception and Emotional Status in Iranian Patients after Heart Transplantation.

Background: Heart transplantation is a major procedure which imposes high emotional stress on patients. Illness perception (IP) is a psychological issue which affects psychological adjustment after transplantation. This study aimed to investigate the association between IP and emotional status in Iranian post-heart transplantation patients. Methods: The present cross-sectional study, conducted between 2018 and 2019 in Imam Khomeini Hospital, Tehran, Iran, recruited 121 post-heart transplantation patients. IP was measured using the Brief Illness Perception Questionnaire (B-IPQ), and emotional status was measured using the Hospital Anxiety and Depression Scale. The association between IP and depression/anxiety was assessed. Results: Men comprised 80.2% of the study population. The mean age of the participants was 43.9±12.95 years. Definite caseness for depression and anxiety was reported in 11.6% and 18.2% of the participants, respectively. The median score of IP was 55. The association between anxiety and IP in total IP and the 3 dimensions of IP was statically significant (P=0.015, P=0.018, P=0.002, and P=0.023 for the cognition, emotion, and understanding dimensions and the total IPQ, respectively). Additionally, the association between depression and IP was significant (P=0.001, P=0.029, and P=0.002 for the cognition and emotion dimensions and the total IPQ, correspondingly, except for the understanding dimension). Furthermore, lower levels of anxiety in the patients showed a greater impact on IP than did depression. Conclusion: There was a significant association between IP and depression and anxiety in our study population. Therefore, the diagnosis and management of anxiety and depression in heart transplantation patients may improve IP. The cross-sectional design of the present study precluded an investigation of the causality between IP and emotional status.

Postoperative pericardial effusion and posterior pericardiotomy, related or not?

INTRODUCTION: Large pericardial effusions after cardiac surgery develop in 30% of patients and reach their maximum size on approximately day 10 postoperatively. Tamponade develops in approximately 1% of patients with large pericardial effusions. Effusion may be prevented by posterior pericardiotomy, but its role and possible adverse consequences are controversial. We sought to further investigate the effectiveness of this technique. METHOD: This prospective randomized case-control study was carried out on 410 patients, mean age 68.4 +/- 9.2 years, who underwent coronary artery bypass graft surgery alone or combined with valve surgery during the period between April 2005 and May 2006. A 4-cm longitudinal incision was made parallel and posterior to the phrenic nerve in the pericardiotomy group. Echocardiographic study was performed at the time of discharge and 15 and 30 days after surgery. RESULTS: After 15 and 30 days postsurgery, respectively, 178 (90.2%) and 192 (97%) of patients from the pericardiotomy group and none from the conventional group were free of effusion (P < .05). CONCLUSION: Posterior pericardiotomy is easy to perform and is a safe and effective means to prevent postoperative effusion and its early and delayed adverse consequences.

Assessment of limited chest x-ray technique in postcardiac surgery management.

OBJECTIVES: The objective of this study is to investigate the safety of elimination of chest radiography in the postcardiac surgery Intensive Care Unit (ICU). METHODS AND DESIGN: We compared patients in two different groups of routine CXR (RCXR) and limited CXR (LCXR) and their diagnostic and therapeutic outcome in a University hospital-based single center from 2014 to 2016. 3 CXR in the RCXR group and 1 CXR in the limited group was performed, in addition to on-demand criteria. MEASUREMENT AND MAIN RESULTS: A total of 978 samples were acceptable for analysis which 55.21% of RCXR and 59.50% of LCXR were male patients. In total, 523 abnormalities in RCXR group and 154 occasions in LCXR group resulted in 26.73% diagnostic efficacy for RCXRs and 28.57% for LCXR. From 1956 CXR that was taken in RCXR group, 72 occasions required intervention (3.68%) and 84 cases out of 539 (15.58%) LCXR needed an action to therapy. This means a 14.40% in RCXRs' abnormalities and 56.00% of LCXRs' abnormalities were accompanied with some interventions. CONCLUSIONS: Abolishing routine CXR in the ICUs would not be harmful for the patients, and it can be managed based on their clinical status and other safer imaging techniques.

Resternotomy, a single-center experience.

Background Reoperations are technically more difficult because of the risks associated with reentry in a heart with more advanced pathology, little reserve, and more frequent comorbidities. Routine peripheral cannulation before resternotomy is inadvisable, time-consuming, and has no noticeable role in decreasing the risks of reentry. We present our experience of resternotomy without routine peripheral cannulation. Methods This was a retrospective study on 237 consecutive patients who underwent resternotomy between June 2011 and July 2013. Their mean age was 47.7 ± 18.2 years. We chose the best approach individually, according to lateral radiograph findings, patient risk factors, and previous surgery. Our goal was to observe events intraoperatively and their outcomes postoperatively. Results Mean intensive care unit stay was 3.1 ± 0.9 days. Twenty-one (8.8%) patients died during their hospital stay. The most common cause of death was renal failure in 15 (71.4%) patients, coagulopathy in 4 (19%), and cardiac failure in 2 (9.5%). We had 3 right ventricular, one right atrial, one pulmonary artery, and 2 inferior vena caval tears during resternotomy and dissection; bleeding was controlled easily without peripheral cannulation. Femoral cannulation before resternotomy was performed in one patient who needed an emergency pulmonary embolectomy. Conclusions Based on our experience, resternotomy with central cannulation is a safe strategy, and peripheral cannulation before resternotomy should be reserved for highly selected patients.

Short-term Outcome of Patients with Infective Endocarditis: A Single-center Prospective Study.

OBJECTIVES: To investigate the short-term outcome of patients with infective endocarditis (IE). PATIENTS AND METHODS: We analyzed data from 42 patients with active endocarditis which underwent different cardiac surgeries. An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue and/or blood culture and acute inflammation Gram stains of sample tissue. DESIGN: Collecting data of 42 patients prospectively. SETTING: University hospital single center. PARTICIPANTS: Patients with IE from July 2014 to June 2016. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We collected data of 42 patients in Imam Hospital which is a university-based 1700-bed center. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 mitral valve repair, and only one patient had experienced a subaortic web resection. Seven cases were addict; in which, 5 of them were intravenous abusers. There was 1 porphyric patient which suffered from pethidine reliability. Most of our cases underwent Bentall or tricuspid valve repair operation, and multivalve operation was more scarce. CONCLUSIONS: We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.

Anesthetic implication of tricuspid valve replacement in a patient with acute intermittent porphyria.

Facing a patient with acute intermittent porphyria (AIP), there is narrow safety margin which circumscribe all the therapeutic actions including choice of drugs. This would become even more complicated when it comes to a stressful and drug-dependent process like a cardiopulmonary bypass. According to author's researches, no specific AIP case of tricuspid valve (TV) replacement is reported recently. Furthermore, fast-track anesthesia was safely used in this 37-year-old male known the case of AIP, who was a candidate for TV replacement and removing the port catheter. The patient was extubated subsequently, only 3 h after entering the Intensive Care Unit.

Heart transplant survival rate in Iran: a single-center registry report.

AIM: to determine 1-month and 1-year survival rate in recipients of heart transplants in Imam Khomeini Medical Center. METHODS: we analyzed the outcomes of 69 patients who underwent heart transplantation between 2007 and 2010. The 1-month and 1-year survival rates were calculated, and we assessed prognostic factors such as donor and recipient age and sex, graft ischemic time during surgery, and liver and kidney function tests. RESULTS: increased donor age had a significant negative effect on survival rate (p = 0.005). Sex differences between donor and recipient had no association with transplant outcome and survival rate. The overall 1-month and 1-year survival was 82.6% (n = 54) and 70% (n = 48), respectively. CONCLUSION: heart transplantation is a lifesaving procedure for end-stage heart disorders. Mortality after heart transplantation depends on numerous factors, and thus survival rates differ among centers. The 1-month and 1-year survival rates after heart transplant in our center currently stand at 82.6% and 70%, respectively.

Short crossclamp heart transplantation: a modified technique.

Prolongation of the ischemic time in heart transplantation adversely affects the performance of the donor heart. We compared the impact of ischemic time in 30 patients who had the conventional bicaval method with declamping just after the last anastomosis (group A) and 28 who had a modified short crossclamp technique with declamping after left atrial stump, aorta, and inferior vena caval anastomosis (group B). In the operating room, 4 (13.3%) group A patients need one inotropic and 26 (86.6%) need 2 or more; one (3.3%) needed intraaortic balloon pumping. In group B, one inotropic was used in 7 (25%) patients, 4 (14.2%) need 2 or more, and 17 (60.7%) needed no inotropic. Mean crossclamp time was 80.5 ± 4.7 min in group A and 62.4 ± 5.8 min in group B. Weaning from bypass was faster in group B. Transesophageal echocardiography at the end of the operation showed more complete de-airing in group B. There were no significant differences in intensive care unit stay or the incidence of postoperative neurologic complications between the 2 groups. Easier separation from bypass, even without a hot shot, and better echocardiographic systolic parameters postoperatively are the advantages of this modified technique.

Relation between preoperative mild increased in serum creatinine level and early outcomes after coronary artery bypass grafting.

This study evaluates the effect of preoperative increased level of serum creatinine (Cr) on early outcomes after coronary artery bypass graft surgery (CABG). 1140 patients who underwent CABG in our center were studied. Patients with Cr >2.25 mg/dl or preoperative dialysis and who had off-pump operations were excluded. Group 1 consisted of 892 patients with normal Cr (0.5-1.2 mg/dl) and group 2 consisted of 248 (21.8%) patients with mild increased level of serum Cr (1.3-2.2 mg/dl). Patients in group 1 were younger than group 2. There were more patients with hypertension in group 2, but there were not statistically significant difference between two groups in terms of the frequency of diabetes, smoking, cerebrovascular disease and New York Heart Association (NYHA) class. Left ventricular ejection fraction (LVEF) was lower in group 2. Cardiopulmonary bypass time (CPB) was longer in group 2. Early mortality was 3.2% in group 1 and 8.4% in group 2 (P<0.001). Prolonged ICU stay, low cardiac output, prolonged mechanical ventilation, postoperative atrial fibrillation, postoperative re-exploration and sepsis were more frequent in group 2. Mild increase in serum Cr level preoperatively is a marker of increased early mortality and outcome after CABG.

A case of aortoesophageal fistula.

Aneurysms of the thoracic aorta can have various manifestations, some of which may simulate esophageal diseases, clinically and radiographically. Aortoesophageal fistula is rare and usually fatal. We report a case of aortoesophageal fistula presenting with progressive dysphagia and intermittent episodes of upper gastrointestinal bleeding.

Autologous ring vs. flexible prosthetic ring for ischemic mitral regurgitation.

Ring annuloplasty is the most common strategy for correction of ischemic mitral regurgitation. When a commercial prosthesis is unavailable or too expensive, an autogenous annuloplasty ring can be handmade by the surgeon. The aim of this study was to compare short-term results of mitral valve repair with autologous annuloplasty rings and the SJM Tailor flexible prosthesis. Between March 2004 and April 2006, 100 patients undergoing coronary artery bypass grafting and mitral ring annuloplasty for ischemic regurgitation were randomly assigned to either type of prosthesis. Transesophageal and transthoracic echocardiography showed no significant differences between these techniques in terms of immediate success of the repair and its durability at 3, 6, and 9 months postoperatively. Autogenous rings are easy to make, cost-effective, and always available. Our short-term results suggest that they may be an acceptable alternative to a commercially produced prosthesis for patients with ischemic mitral regurgitation.

Postoperative pericardial effusion and posterior pericardiotomy: related?

Large pericardial effusions develop in 30% of patients after cardiac surgery, and reach their maximum size after 10 days, with tamponade in 1%. The aim of this prospective randomized case-controlled study was to assess the effectiveness of a posterior pericardiotomy in preventing early and late (>30 days) development of pericardial effusion. Between April 2005 and May 2006, 410 patients with a mean age of 68.4 +/- 9.2 years undergoing coronary artery bypass grafting alone or combined with valve surgery were divided into 2 groups of 205 each. In the pericardiotomy group, a 4-cm longitudinal incision was made parallel and posterior to the phrenic nerve. Echocardiography was performed at discharge and 15 and 30 days after the operation. At 15 and 30 days postoperatively, 90.2% and 97% of patients in the pericardiotomy group were free of effusion; while none in the control group were free of effusion. A posterior pericardiotomy is easy to perform and seems to be a safe and effective means of preventing postoperative effusion and its adverse consequences.