2 Payiz 1384 Fall 2005 6 3 146 Aortic root reconstruction remains a challenging surgical procedure. Although several surgical approaches have been introduced, but their mortality and morbidity rate are still high. A.A. Ghavidel, MD; M.B. Tabatabaei, MD; K. Raeisi, MD; M.A. Yousefnia MD; A.J. Khamooshi MD; G. Omrani, MD; N. Givtaj, MD; M.H. Kalantar Motamedi, MD;* M.H, Ghaffarinejad MD; S. Hosseini, MD; A. Yaghoobi, MD; H. Javadpour MD and M. Gholampour, MD Aortic root reconstruction remains a challenging surgical procedure. Although several surgical approaches have been introduced, but their mortality and morbidity rate are still high. This study was carried out to evaluate the early and mid-term outcome of aortic root replacement in a referral center in Iran. Between March 1993 and April 2003, 83 patients who underwent Bentall operation were studied. The mean age was 43.2±14 years, ranging from 10 to 78 years old. 78.3% of cases were male. Dyspnea and chest pain were the most common complaints. Aortic dissection (type A) was seen in 28% of cases and 24% had Marfan syndrome. Emergent operation was done in 18.1%. The average cardiopulmonary bypass (CPB) time was 155.3±61 minutes and aortic cross clamp time was 106.8±35 minutes. Follow-up period ranged from 1 to 120 months with a mean of 29.6±28 months. The overall mortality rate was 15.7% (13 cases). Eleven deaths occurred in the hospital during the early postoperative days, and two deaths occurred within the follow-up period. Severe left ventricular failure, sepsis and bleeding were the most important causes of death. Two deaths occurred as a result of resistant tachyarrhythmia and acute MI. The mortality rate was significantly higher in those who presented with cardiogenic shock, had longer CPB and aortic cross clamping (AOX) time and finally in the cases with concomitant coronary artery bypass graft (CABG) surgery. Age, sex, underlying disease, pathology, ejection fraction, surgeon, emergent operation, Marfan syndrome, surgical techniques, amount of post- operative bleeding and the severity of aortic insufficiency did not affect mortality significantly. The neurological problems and postoperative mediastinal bleeding were the most common complications. The early mortality rate in our series was relatively higher than the other studies; however, the mid-term survival in our series was excellent. The clear risk factors for early mortality in our investigation were CBP time>180min, AOX>120min, presentation with cardiogenic shock and concomitant CABG. Despite the previous reports, factors like emergent operation, age>65 and LVEF<40% were not predictors for higher mortality rates in our study. We hope to offer a better prognosis by improvement of operative technique, good myocardial and cerebral protection and reducing the CPB and AOX times (Iranian Heart Journal 2005; 6 (3): 6-14). aortic root reconstruction Ë aortic dissection Ë aneurysm of ascending aortaË Bentall procedure. 147 Alireza Jalali, MD, Lal Dolat Abad, MD, Aziz Ebrahimi, MD, H. Habibi, MD* and M. H. Kalantar Motamedi, MD CABG is one of the most common surgical procedures, especially among heart surgeries. Protection of the myocardium during and after the early stages of operation has special importance. Different medical and drug techniques have been used for this purpose. One of these techniques is infusion of glucose-insulin-potassium (GIK) solution. We compared the efficacy of GIK solution and GIK- magnesium (Mg) in two groups. The first group received GIK solution without Mg and the second group GIK plus Mg solution, to protect the function of the myocardium. In a double-blind randomized study, we selected 50 patients as candidates for CABG with left ventricular ejection fraction (LVEF) less than 30% and without any severe lung, kidney and blood diseases. These 50 patients were divided in two equal groups. After induction of anesthesia with the same method for both groups, we infused 10 ml/hr GIK in the first group and the same amount of GIK-Mg in the second group for 10 hours in each group and the length of the time and the amount of solution were equal and also stages of induction and maintenance of anesthesia in both groups were similar. We studied vital signs, hemodynamic parameters and complications in both groups during induction, cardiopulmonary bypass (CPB), during stages of weaning these patients from CPB, during their stay in the ICU and until discharge from the hospital. Complications such as sudden fibrillation, arrhythmias, ST elevation during weaning the patients from CPB, intubation time and stay in hospital and ICU in the GIK-Mg group were significantly less than the GIK without Mg group. More importantly, the average percentage of LVEF on discharge in the GIK-Mg group was higher than the group without Mg solution. Our study demonstrated that infusion of GIK-Mg is more effective in protection of myocardial function and decreasing complications in CABG patients with LVEF less than 30% than GIK without Mg solution. So, it is recommended that in such patients, GIK-Mg solution should be used routinely (Iranian Heart Journal 2005; 6 (3): 15-21). glucose ■ insulin ■ potassium ■ magnesium ■ myocardial protection ■ coronary artery bypass 148 Afsoon Fazlinezhad, MD; Majid Maleki, MD; Fereidoon Noohi, MD; Seiedeh Zahra Ojaghi, MD; Mohammad Sahebjam, MD and Roghayeh Sepordeh, RN Left atrial appendage contraction velocity (LAAV) is used frequently as a surrogate for global left atrial function, but the validity of this parameter for the prediction of left ventricular systolic and diastolic function has not been evaluated extensively. The objective of this study was to assess the relationship between LAA contraction flow velocity and left ventricular systolic and diastolic function parameters. This study was performed on 142 patients-62 male (43.5%) and 80 female (56.5%) – who were referred for an evaluation of the source of emboli. Exclusion criteria were significant valvular abnormality, prosthetic valve replacement and congenital heart disease. The correlation between LAA contraction velocity and systolic ventricular function was significant (p value=0.05). There was an inverse relation between LAA contraction velocity and LV contraction: in 78 patients with LVEF<50%, mean LAAV was about 29cm/s, while in 64 patients with LVEF>50%, mean LAAV was about 50cm/s. Regarding diastolic flow parameters and pulmonic vein flow, patients were classified into four groups as follows: 1) 76 cases with normal patterns, 2) 38 cases with impaired LV relaxation, 3) 16 cases with pseudo-normalization and 4) 12 cases with restrictive patterns. Statistical analysis did not show significant correlation between LAAV and diastolic function (p=0.236). Correlation between diastolic function parameters and LAA contraction velocity revealed a significant relation between LAAV and A wave velocity of mitral inflow (p=0.02) and no significant relation between LAAV and other diastolic parameters including E wave velocity, DT and IVRT (p=0.66, p=0.73, p=0.79). ECG showed 98 cases with normal sinus rhythm (NSR), 9 with complete atrioventricular block (CAVB) and 35 with atrial fibrillation (AF). There was a significant reduction in LAAV in AF rhythm compared to NSR. LAA contraction velocity has a close relation with LV systolic function, but not diastolic function. Therefore, LAA contraction velocity should be considered a surrogate for left ventricular systolic function (Iranian Heart Journal 2005; 6 (3): 22-28). echocardiography Ë left atrial appendage Ë contraction velocity Ë left ventricular function 149 Nozar Givtaj, PhD; Mohammad K. Taraghi, MD; Alireza Bandegani, MD; Nader Givtaj, MD and Abbas Zavarehee, PhD One of the most common causes of hospital admissions is chest pain of ischemic origin; a number of such cases tend to be diagnosed as acute myocardial infarction (MI) and sent to CCUs. Earlier diagnosis in these patients, particularly in those without typical signs of MI, results in better and faster service to the patient and, therefore, reduces the rate of mortality. The special role of cardiac enzymes in diagnosing myocardial infarction has been known for a long time. This study sought to investigate the sensitivity and specificity of myoglobin in MI diagnoses. As regards the role of inflammatory factors in MI, the relationship of C-reactive protein (CRP) and MI was also investigated. Seventy-eight patients presenting to our emergency department with acute chest pain were interviewed. After it had been confirmed that they fulfilled the inclusion criteria, samples were collected for measurement of myoglobin, CRP and CK-MB. The measurement was repeated after six hours. All the patients who were diagnosed as having myocardial infarction had myoglobin levels higher than normal, which demonstrated 100% sensitivity and NPV of this test for the diagnosis of acute MI (AMI). However, the plasma level of myoglobin was also higher than normal in about 20% of the non-MI patients, which showed that the specificity of this test was about 78% and the accuracy of the test was 87%. The CRP level was also higher in MI patients in comparison to non–MI patients. The results of this study and similar studies demonstrated that myoglobin measurement for the patients referred to the emergency ward should be taken at least twice, i.e. once upon admission and then after six hours. Furthermore, CRP evaluation on the first day can result in better and faster diagnoses of such patients (Iranian Heart Journal 2005; 6 (3): 29-32). acute myocardial infarction Ë myoglobin Ë CRP 150 Z. Ojaghi, MD; M. Karvandi, MD; F. Noohi, MD; M. Maleki, MD; and A. Mohebbi, MD The assessment of pulmonary artery pressure is important in clinical management and prognostic evaluation of patients with cardiovascular and pulmonary disease. Today, the accurate measurement of pulmonary artery pressure requires the use of cardiac catheterization. However, reliable non-invasive evaluation of pulmonary pressure still presents a problem. The purpose of the present study was to determine whether the isovolumic relaxation time (IVRT) obtained by pulsed Doppler tissue imaging from tricuspid annular motion could be used as an index of pulmonary pressure in patients with valvular, coronary and congenital heart disease. Simultaneous tissue Doppler echocardiography and right heart catheterization were performed in 80 patients (mean age 46 years, 36 male) with valvular heart disease (n=59), coronary heart disease (n=20) and congenital heart disease (n=15). The patients were divided into three groups: group I: pulmonary systolic pressure (post-LV injection phase) in 25-40 mmHg range (n=28); group II: 41-60 mmHg range (n=37); and group III: 61-100 mmHg range (n=15). The isovolumic relaxation time (IVRT) was measured from the tricuspid annulus in apical 4C view at the junction of the right ventricular free wall and the anterior leaflet of the tricuspid valve by tissue Doppler imaging. Cardiac catheterization and pulmonary artery systolic-diastolic pressures (pre-LV injection and post-LV injection phase) were measured. The IVRT was compared with pulmonary artery systolic- diastolic pressures by means of linear regression analysis. There was a significant correlation in all the groups between the IVRT and the sum of pulmonary artery systolic-diastolic pressures in post-LV injection phase (r= 0.99, P<0.0001). The linear regression equation is: IVRT= [(PA systolic pressure in post-LV injection phase) + (PA diastolic pressure in post-LV injection phase)] ± 5. Some factors such as RV function, underlying disease (valvular, coronary, congenital heart disease), age and sex have no effect on the calculated formula. The IVRT value was compared in the three groups: group I: 51.79 ms± 8.35 STD; group II: 74.19ms ± 10.51 STD; and group III: 108.27ms± 16.43 STD. The IVRT values between the three groups had significant differences (P<0.0001). An IVRT ≥ 77 ms predicted pulmonary artery systolic pressure (Post LV injection phase) ≥ 50 mmHg with a sensitivity of 93% and a specificity of 80%. We conclude that the evaluation of the isovolumic relaxation time from the tricuspid annulus by Doppler tissue imaging provides a simple, rapid and non- invasive tool for estimating pulmonary pressure in patients with valvular, coronary and congenital heart disease(Iranian Heart Journal 2005; 6 (3): 33-38) pulmonary artery pressure Ë tissue Doppler imaging Ë isovolumic relaxation time 151 M. Momtahen, MD; M. Nayebpour, PharmD, PhD and S. Sadighi, MD Angiotensin II promotes atherogenesis and modulates plaque vulnerability mainly by stimulating inflammatory mechanisms. The aim of this study was to investigate changes in the plasma level of angiotensin II in acute coronary syndrome. The plasma level of angiotensin II was measured using the radioimmunoassay method in 81 patients with acute coronary syndrome, consisting of 34 patients with unstable angina and 47 patients with acute MI, and in 80 non-ischemic patients (control group). The plasma level of angiotensin II was significantly higher in the acute MI patients than that in the control group (11.3±7.50 pg/ml versus 9.72±8.30 pg/ml, P value<0.05) (Iranian Heart Journal 2005; 6 (3): 39-41). acute coronary syndrome Ë angiotensin II 152 Majid Haghjoo, MD, Arash Arya, MD, Zahra Emkanjoo, MD and Mohammad Ali Sadr-Ameli, MD By analyzing stored intracardiac electrograms during spontaneous monomorphic ventricular tachycardia (VT), we examined the possible mechanisms of the VT initiation in a group of patients with implantable cardioverter defibrillators (ICDs) Stored electrograms (EGMs) of monomorphic VTs from at least 5 beats before initiation and after the termination of VT were analyzed. Cycle length, sinus rate, and the prematurity index for each episode were noted. We studied 182 episodes of VT among 50 patients with ICDs. Ventricular premature complex (VPC) -induced episode (extrasystolic initiation) was the most frequent pattern (106; 58%), followed by 76 episodes (42%) in the sudden-onset group. Among the VPC-induced group, VPCs were different in morphology from subsequent VT in 85 episodes (80%). Sudden-onset episodes had longer cycle lengths (377±30ms) in comparison with the VPCinduced ones (349±29ms; p= 0.001). Sinus rate before VT was faster in the sudden-onset compared to the VPCinduced group (599±227ms versus 664±213ms; p=0.005). Both of these episodes responded similarly to ICD therapy. There was no statistically significant difference in coupling interval, prematurity index, underlying heart disease, ejection fraction, and antiarrhythmic drug use between the two groups (p=NS). Dissimilarities between VT initiation patterns could not be explained by differences in electrical (coupling interval, and prematurity index; p=NS) or clinical (heart disease, ejection fraction, and antiarrhythmic drugs; p=NS) variables among the patients. Information obtained by the analysis of stored EGMs could be helpful for the understanding of VT electrophysiology (Iranian Heart Journal 2005; 6 (3): 42-48). ventricular tachycardia ■ defibrillator, implantable ■intracardiac electrogram 153 Davood Kazemi Saleh, MD; E. Kassaian, MD*; M. Salarifar, MD*; A. Zainali, MD* and M. Alidoosti, MD* It has been shown that the socioeconomic and cultural status of adults in industrialized countries is related to cardiovascular disease mortality and morbidity. It has been shown also that higher education was associated with reduced mortality from all causes, cardiovascular diseases, and coronary heart disease in both genders. The aim of this study was to evaluate whether or not educational level of patients influences success, mortality rate, complications and late outcomes of PCI. 1030 consecutive patients who underwent PCI in Tehran Heart Center from April 2003 to March 2004 were analyzed. The patients were divided based on their educational level in three groups: Group A: no education, Group B: below diploma (high school), Group C: diploma and above. Results were analyzed regarding success rate, early and late outcomes in each educational group. Follow up period was about 8 months. 25% (256) of our patients were in group A, 45% (461) in group B and 30% (315) in group C. There were significant differences regarding incidence of hyperlipidemia, previous MI, CABGS or PCI. The rate of ad hoc PCI procedures was significantly higher in group C compared to groups A and B. This study has shown no significant relationship between the level of education of patients who underwent PCI procedure and their procedural success rate, mortality and other early and late outcomes (Iranian Heart Journal 2005; 6 (3): 49-53). education level Ë percutaneous coronary intervention 154 Hossein Nough, MD;* Hashem Sezavar, MD;** Ahmad Mohebbi, MD*** and Feridoon Noohi, MD*** Animal studies have indicated the effects of iron stores in the process of free radical formation and low density lipoproteins (LDL) oxidation. Oxidation of the lipids especially LDLs by oxidants such as iron has a central role in atherogenesis. As a result, evaluating the amount of iron stores in patients with coronary artery diseases may be of importance. In this prospective study, 112 patients with coronary artery disease (CAD) and 63 normal individuals were investigated. The coronary condition of the subjects was determined by coronary angiography. The amounts of iron, ferritin, total cholesterol, triglyceride, LDL and HDL were measured in both groups. The subjects were also evaluated for known CAD risk factors including diabetes mellitus, hypertension, smoking, family history of CAD and hyperuricemia. The subjects suffering form anemia, renal and hepatic diseases and those with a history of malabsorption, hemochromatosis, chronic infections or immunological and inflammatory disorders and patients with neoplastic diseases and cardiac failure were excluded from the study. Moreover, all the subjects had a similar socioeconomic status. Mean serum iron was 12.9±4 μmol/l and 10.8±5 μmol/l in the group with CAD (case) and in the group without CAD (control), respectively, which was significantly different (p<0.001). Mean serum ferritin was 126±75 μgram/l in the case group, while it was 101±75 µgram/l in the control group: this was also significantly different (p<0.005). The findings indicate that serum levels of iron and ferritin - excluding other known risk factors - in patients with CAD are higher compared to the subjects without CAD. Consequently, iron stores in the body may play a role in the atherosclerotic process (Iranian Heart Journal 2005; 6 (3): 54-58). ferritin ■ coronary atherosclerosis ■ serum iron 155 Roozbeh Naghshin, MD;* Mohammad Massood Zaker, MD;** and Amin Ehteshami Afshar, MD*** Many studies have suggested a relationship between the six-minute walk test (6MWT) and pulmonary function test (PFT) parameters in patients with chronic obstructive pulmonary disease (COPD). This study was designed to assess the association between individual PFT parameters and the 6MWT results in our COPD patient population. Fifty-five patients with COPD (45 men and 5 women), defined as FEV1/FVC < 0.7, were recruited in this study. Spirometry parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow rate (PEFR) and FEV1/FVC ratio, were measured. All the patients underwent the 6MWT within one hour of spirometry. All the COPD subjects were classified as mild, moderate or severe as per ATS criteria. There was a statistically significant association between the results of the 6MWT and FEV1, FVC% and PEFR (all p values < 0.001). However, our study did not show any relationship between FEV1 to FVC ratio and the 6MWT results (r = 0.09 and p = 0.52). Using one way analysis of variance, we found a significant relationship between the severity of COPD and the result of the 6MWT (f = 8.78 and p < 0.001). In our COPD patient population, the result of the 6MWT correlated with FEV1, FVC%, as well as PEFR%. This suggests that spirometry data could also be useful in long-term management of COPD patients (Iranian Heart Journal 2005; 6 (3): 59-63). six-minute walk test Ë chronic obstructive pulmonary disease Ë pulmonary function test 156 Ali Akbar Tavasoli, MD; Masoumeh Sadeghi, MD; Masoud Pourmoghaddas, MD and Hamid Reza Roohafza, MD Many risk factors have been reported to be higher among hypertensive than normotensive subjects. This study was an effort to determine the prevalence and types of dyslipidemia among the hypertensive population. This case-control study was performed on 1500 participants over 30 years of age between 1998 and 2001. The case group consisted of uncomplicated non-diabetic hypertensive patients, and the control group was composed of normotensive individuals. First a questionnaire containing demographic details, drug intake and smoking status was completed. Then physical examination, including systolic and diastolic blood pressure (SBP, DBP) and body mass index (BMI), was performed. Fasting blood sample was drawn for sugar (FBS), total cholesterol (TC), triglyceride (TG) and low and high density lipoprotein cholesterol (LDL-C and HDL-C). Data were analysed in SPSS V11 /Win by using t-test and Chi-square test. Mean age in the case and control groups was 51.03±18.7 and 50.84±19.3, respectively. TC and LDL-C levels were higher in the hypertensive population, and this just reached statistical significance. There were no significant differences in HDL-C and TG levels. LDL-C was also significantly higher in the female hypertensives as compared to the males and also in comparison with the controls. TG and HDL-C levels were not significantly different in either sex in the two groups. The overall prevalence of dyslipidemia was more than 75 percent in the case and nearly 70 percent in the control group. Hypercholesterolemia and high LDL-C were more prevalent in the case compared to the control group. These results indicate that hypercholesterolemia and high LDL-C are the more common variety of dyslipidemia in uncomplicated hypertension and that we must consider primary and secondary prevention with life style modification and drug therapy in hypertensive patients (Iranian Heart Journal 2005; 6 (3): 64-69). lipid profile ■ hypertension ■ cholesterol ■ triglycerides 157 Jalal Vahedian, MD; FIAS; Gholamreza Omrani, MD and Ali Sadeghpour, MD Behçet’s disease is an uncommon multisystemic disorder that appears most often in the third or fourth decade of life. It is characterized by recurrent orogenital ulcers and ocular and cutaneous inflammatory lesions.Cardiovascular involvement, which may be arterial or venous, is rare but carries a particularly poor prognosis. Arterial involvement is less frequent, constituting 12% of cardiovascular complications. The arterial findings in this disease may be occlusions and aneurysms or pseudoaneurysms of the aorta and pulmonary, brachial, carotid, subclavian and visceral arteries. In this report, we present a 41-year-old man having suffered from Behçet’s disease for more than 12 years, complicated by a big bi-saccular aneurysm of the 1st and 2nd portions of the left subclavian artery. The presenting symptoms and signs were thromboembolic arterial occlusion and brachial plexus compression (Iranian Heart Journal 2005; 6 (3): 70-75). Behçet’s disease Ë subclavian arterial aneurysm Ë thromboemboli Ë brachial plexopathy