15 Bahar 1385 Spring 2006 7 1 132 A. Afrasiabi MD, M. Pezeshkian MD, B. Rastkar MD, M. Samadi MD, N. Safaei MD and H. Montazergaem MD Decision making for closure of large ventricular septal defect (VSD) with increased pulmonary vascular resistance (PVR) sometimes is difficult. In this prospective study, we report our experience in patients undergoing closure of large VSD with a valve-patch. Between March 1998 and December 2004, acyanotic patients with large VSD and pulmonary artery hypertension were selected for surgery. In all the patients, Gortex patch material was used, and a longitudinal slit (5-8 mm) was made in the middle part of it. A pericardial piece was sewn around the slit on one side of the Gortex patch except in the upper part. Usually via the right atrial approach, the VSD was closed with trimmed Gortex patch with the pericardial valve-patch located on the left ventricular side, allowing it to open for probable right to left shunt. Sixteen patients with a mean age of 7±5.7 years and PVR of 9.6±3.8 Wood units underwent operation. All the patients were weaned off cardiopulmonary bypass successfully and sedated for at least 18-24 hours. Echocardiography on the same day of operation revealed right to left shunt in 6 cases. Two patients died in the early postoperative period. One child died due to frequent episodes of pulmonary hypertensive crisis and the other with persistent severe pulmonary hypertension and systemic low oxygen saturation. In three years’ follow-up, PVR gradually regressed except in one case, in which PVR increased with right-to-left shunt and cyanosis. Valve patch technique in severe pulmonary artery hypertensive cases is a promising technique to decrease morbidity and mortality; however, in sustained or elevated PVR it may have deleterious effects in the early and late postoperative periods(Iranian Heart Journal 2006; 7 (1): 6-10). ventricular septal defect ■ pulmonary hypertension 133 Nasser Ali Hodjati MD, Zohreh Karkhaneh Yousefi MD and Mehdi Manzari MD Inappropriate inflammation is a key mechanism in the development of atherosclerosis. Antibodies against components of the atherosclerotic lesion, in particular, oxidized low density lipoprotein, have been described. The prevalence of systemic autoimmune reactions as characterized by the presence of high titers of serum antinuclear antibodies have also been reported in patients with advanced coronary atherosclerosis. This study was performed to determine whether or not a systemic autoimmune response, characterized by the presence of high titers of antinuclear antibodies, is associated with the presence of coronary atherosclerosis. In this case-control study, serum was prepared from 55 subjects (aged 59±9.3) with at least 50% stenoses of three main coronary arteries (3VD subjects), and 41 subjects (aged 52.6±7.6) with no evidence of coronary atherosclerosis (NCA subjects) as determined by coronary angiography. The presence of antinuclear antibodies (ANA) was determined by HEp-2 cell as the substrate using DAKO kits (FITC conjugated rabbit anti-human antibodies) for IgA, IgG, IgM and IgK. The titers of 1/40 or more were considered positive. Observers who graded the test results were unaware of the angiograms. Ninety-six subjects (mean age 55.8±9.3 years, 40-76 years old) entered the study. Demographic and clinical variables were matched among case and control groups except for age and gender. 3VD groups were older (59±9.3 vs. 52.6±7.6, p<0.001) and most of them were male (57.3% vs. 42.7%, p<0.02). Among the NCA group, 11 of 41 subjects (27%) were ANA positive and among 3VD patients, 15 of 55 subjects (26.2%) were ANA positive (p=0.978). The presence of ANA, commonly associated with autoimmune diseases, is not substantially more prevalent among subjects with severe coronary atherosclerosis than those with normal coronary arteries. There is no evidence of autoimmune and systemic markers in both groups. This association does not merit further assessment as a potentially useful indicator of increased risk of coronary heart disease (Iranian Heart Journal 2006; 7 (1): 11-14). antinuclear antibodies ■ coronary artery disease ■ autoimmune disease 134 Masoumali Masoumi MD, Feridoun Sabzi MD, Zahra Jalili MD, Fereshteh Keshavarz MSc, Mostafa Ghanbari MSc and Gholamreza Abdoli, MSc Antegrade and retrograde infusion of cardioplegia may provide more homogenous distribution of cardioplegia, especially in cases of coronary artery disease, but it has not been tested in tetralogy of Fallot repair. The purpose of this study was to compare antegrade and intermittent antegrade-retrograde cardioplegia on myocardial function following total correction of tetralogy of Fallot. Antegrade and retrograde infusion of cardioplegia may provide more homogenous distribution of cardioplegia, especially in cases of coronary artery disease, but it has not been tested in tetralogy of Fallot repair. The purpose of this study was to compare antegrade and intermittent antegrade-retrograde cardioplegia on myocardial function following total correction of tetralogy of Fallot. The two groups had similar preoperative characteristics (age, sex, body mass index). The mortality was 1 (3.8%) in group A and 5 (19%) in group B (P<0.05). Postoperative infusion of epinephrine and the dosage used were higher in group B (P<0.022), but the duration of its use was not different. Need for dobutamine, its dosage and duration of use were different in group B (P<0.002, P<0.007 and P<0.001, respectively). Dopamine infusion, dosage and duration were significantly different in the two groups (P<0.011, P<0.034 and P<0.011, respectively). Significant differences for ventilatory support were seen in the two groups (P< 0.043), but ICU stay in the two groups was not significantly different. In light of our findings, it is concluded that there is a significantly better postoperative myocardial performance and lower mortality following antegrade-retrograde cardioplegia. We consequently recommend it as a routine method for myocardial protection in non-infantile repair of tetralogy of Fallot (Iranian Heart Journal 2006; 7 (1): 15-20). cardioplegia ■ myocardial protection ■ tetralogy of Fallot ■ congenital heart surgery 135 M. Sadeghi M.D.; S. Khezri M.D.; and A. Mehraein M.D. Cardiac diseases managed with surgery are growing increasingly because of technologic progress and sedentary lifestyles on one hand and progression of diagnostic procedures on the other. Thyroid dysfunction and alterations in thyroid hormones have a direct effect on the cardiovascular system, and special attention to this issue is required to counter the effects of these two systems (thyroid hormones and cardiovascular system) on each other, especially during and after cardiac surgery and resultant thyroid hormone alterations due to surgery. Frequent use of cardiopulmonary bypass (CPB) during cardiac surgical procedures makes this issue very important. The goal of this research is to study thyroid hormone alterations after cardiopulmonary bypass and its effect on hemodynamic parameters and weaning time of patients from ventilatory support after cardiac surgery Sixty patients undergoing CPB who had no previous history of thyroid disease and who did not have any diseases affecting weaning time from ventilator were studied. Thyroid hormone levels were measured before and after CPB, and hemodynamic parameters (including mean arterial pressure, heart rate and central venous pressure) were measured every 5 minutes in the operating room and every 15 minutes in the ICU. The time of patient arrival to the ICU until extubation of the patient (after meeting the criteria of extubation) was measured in minutes, and the relations between the variables were studied. Among all the variable parameters, the correlation between free T3 (FT3) and CVP after discontinuing CPB; TSH alterations and heart rate at arrival to ICU; and TSH alterations and time-to-extubation of the patient were statistically meaningful (P<O.O5). Except for the relation between TSH alterations and HR upon arrival to the ICU, the others had “low predictive value” and the latter had “medium predictive value”. Thyroid hormones differ after CPB, and this difference has correlations with hemodynamic parameters and time-to-extubation of the patient (weaning time). Thyroid hormones■ Hemodynamic parameter changes■ Cardiopulmonary bypass ■ Weaning time 136 Hamid Reza Nasri MD, Mohammad Maasoomi, MD and Mostafa Motefakker MD* Risk factors for 30-day hospital readmission following coronary artery bypass grafting (CABG) have not been established. Recent studies have reported readmission rates after CABG ranging from 7.1% to 21%, and causes of readmission have varied in different studies. This study was conducted to evaluate probable risk factors of increased morbidity following CABG surgery during the first 30 postoperative days. A total of 545 patients who had undergone CABG were followed prospectively for 30 days after surgery. The patients were contacted by telephone to determine readmission. If re-hospitalized in the first 30 days after surgery, the patients were visited and data were collected and analysed. Sixteen out of 545 patients were readmitted. The overall 30-day hospital readmission rate was 2.9%. The most common reason for readmission was sternal infection. There were no significant differences between readmitted and non-readmitted cases in demographic and clinical variables. Unlike other studies in which some factors like female gender and length of hospital stay were risk factors for 30-day hospital readmission after CABG, our data did not show these as predictors of re-hospitalization (Iranian Heart Journal 2006; 7 (1): 25-30). coronary artery bypass grafting ■ hospital readmission ■ risk factors 137 A. Shahmohammadi MD, P. N. Davari MD, Y. Aarabi MD, M. Meraji MD, A. Tabib MD and H. Mortezaeian MD Cardiac involvement which leads to congestive heart failure (CHF) is a major cause of death in patients with thalassemia major due to hemosiderosis and chronic anemia. Although the left ventricular (LV) systolic function in patients with thalassemia major has been considerably studied, LV diastolic function has not been assessed adequately. In this current study we used Doppler echocardiography to assess LV function. The aim of our study is to investigate the consequences of chronic anemia and transfusional iron overload on the LV function, especially the diastolic filling pattern in patients with thalassemia major. We sought to test the hypothesis of measurement of myocardial performance index (MPI) and isovolumetric relaxation time (IVRT) in an early stage of the disease, when iron overload has not yet caused irreversible changes. 65 patients with thalassemia major in New York Heart Association (NYHA) class I, II who have been treated with desferioxamine with mean age of 11±3 years were randomly selected and assessed by Doppler echocardiography and the data were compared prospectively with those obtained in 48 age and sex-matched normal subjects. MPI was increased in thalassemic patients compared with normal control subjects (0.42 ± 0.06 vs. 0.34 ± 0.04, P value=0.015). IVRT was increased in patients vs. compared to controls (60±11 msec vs. 42±6 msec, P value=0.020), indicating impaired relaxation in the early stage of LV diastolic dysfunction due to hemosiderosis. The peak velocity in late diastole (A) was increased in patients compared to controls (54±6 cm/sec vs. 38±4cm/sec, P value=0.034), while the ratio between the early and late peaks of flow velocity (E/A ratio) was reduced (1.3±0.2 vs. 1.8 ± 0.3, P value=0.028). E deceleration time was increased in patients compared to controls (180±28 msec vs. 140± 26msec, P value=0.044), whereas no difference was found in left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) in patients compared to controls (LVEF 60±8, vs. 64±6, P value 0.068) and (LVFS 34±6 vs. 36± 4, P value=0.072). Left ventricular end-diastolic volume (LVEDV) was increased in patients compared to controls (52±12 cc/m2 vs.38±8 cc/m2, P value=0.012), indicating effects of chronic anemia on LV function The findings of this study also suggest that chelating therapy does not completely protect patients with thalassemia major from myocardial damage due to iron – related cardiac toxicity and there was no correlation between ferritin level and LV dysfunction. Evaluation of diastolic function and measurement of MPI and IVRT are simple and useful in early detection of LV dysfunction, especially in asymptomatic young patients in an early reversible stage of the disease when iron overload has not yet caused systolic dysfunction (Iranian Heart Journal 2006; 7 (1): 31-36). myocardial performance index ■ isovolumic relaxation time ■ left ventricular end diastolic volume 138 Ahmad A. Yousefi MD, Nozar Givtaj* PhD, Abbas Zavarehee PhD*, Navid Sabourizadeh MD and Mohammad R. Chizaree, MD Coronary artery disease (CAD) is the major cause of death in the world today.1 Many factors are responsible for causing CAD, but some patients have none of the known major risk factors, i.e. hypertension, diabetes, smoking, hyperlipidemia and family history of CAD.2 Recent studies suggest other factors such as lipoprotein a (LPa), fibrinogen and homocysteine as risk factors for CAD.1 The present study tries to establish the relationship between these three factors with CAD in patients with no other major known risk factor(s). Sixty-four patients without any known major risk factors whose angiographies showed significant disease in their coronary arteries were selected. Their blood samples were obtained, and their serum homocysteine, fibrinogen and LPa levels were determined. 9.4% of the cases investigated had elevated fibrinogen levels above normal. This was also true for 42.2% and 87.5% of the cases in terms of homocysteine and LPa, respectively. Therefore, of these three factors, LPa seems to have the strongest and fibrinogen the weakest relation with CAD. The results of this study and similar studies indicate that these three factors, particularly homocysteine and LPa, could be considered as independent risk factors for CAD and that controlling them would be a significant step toward preventing cardiovascular diseases (Iranian Heart Journal 2006; 7 (1): 37-39). Lipoprotein a ■ fibrinogen ■ homocysteine ■ CAD 139 Hamid Nasri, MD, Azar Baradaran, MD,* and Forouzan Ganji, MD** Two principal findings of cardiovascular disease in end-stage renal disease patients undergoing regular hemodialysis are left ventricular hypertrophy (LVH) and arterial disease due to rapidly progressive atherosclerotic vascular disease that can be characterized by an enlargement and hypertrophy of arteries (intima-media complex thickening, IMT). In this study, we sought to study the relationship between left ventricular hypertrophy with intima-media complex thickening in end-stage renal disease patients undergoing regular hemodialysis. Sixty-one unselected patients with end-stage renal disease (ESRD) who were undergoing regular and maintenance hemodialysis treatment (F=23, M=38) were studied. The subjects consisted of 50 non-diabetic hemodialysis patients (F=20, M=30) and 11 diabetic hemodialysis patients (F=3, M=8). For all the subjects, echocardiography and carotid intima-media thickness measuring by B-mode ultrasonography were performed. In this study, there was a positive correlation between stages of LVH with duration of hemodialysis treatment, stages of hypertension (HTN), and with carotid-IMT. A positive correlation was also seen between stages of LVH and presence of chest pain, and more thickening of the intima-media complex was seen in the diabetic group. Diabetes mellitus was associated with the presence of chest pain, as was positive correlation between stages of HTN with IMT, and a reverse correlation was observed between IMT with the percent of cardiac ejection fraction. Prevalence of thickening in intima-media complex is more evident in hemodialysis subjects with LVH. When there is LVH, IMT is similar in severity to the LVH (Iranian Heart Journal 2006; 7 (1): 40-46). intima-media thickness Ë hemodialysis Ë left ventricular hypertrophy Ë atherosclerosis Ë diabetes mellitus 140 Arash Arya MD, Mohammad Ali Sadr-Ameli MD, Majid Haghjoo MD, Babak Kazemi MD and Zahra Emkanjoo MD One of the most important challenges in today’s practice of cardiology is prevention of sudden cardiac death (SCD) in high risk patients with coronary heart disease (CAD). Hemodynamically-tolerated sustained ventricular tachycardia (HTVT) comprises up to 30% of all cases of monomorphic ventricular tachycardia (MMVT) in patients with CAD. While there is a consensus on treatment of hemodynamically-unstable sustained VT in patients with CAD, some controversies regarding the proper treatment of HTVT exist. We re-examined existing clinical evidence, controversies and current guidelines on the treatment of HTVT in patients with CAD and demonstrated that compared to implantable cardioverter-defibrillators, amiodarone is not an acceptable therapeutic option in patients with ischemic heart disease who suffer from HTVT (Iranian Heart Journal 2006; 7 (1): 47-55) coronary artery disease■ ventricular tachycardia■ implantable defibrillators■ amiodarone 141 Seyyed Mahmoud Meraji MD, Shamsi Ghaffari MD and Keyhan Sayyadpour Zanjani MD We report successful occlusion of the fenestration after total cavopulmonary connection operation due to cyanosis with the Amplatzer septal occluder device. The procedure was satisfactory; arterial oxygen saturation increased markedly and the general condition of the patient improved remarkably. This procedure was done for the first time in the Islamic Republic of Iran. A residual communication or fenestration between systemic and pulmonary venous return is often created during surgical construction of the Fontan circulation. This fenestration may prevent excessive increases in venous pressure in the early postoperative phase, especially in high risk patients.1,2 Many of these fenestrations close spontaneously;3 however some remain open causing persistent arterial desaturation and are a potential cause of paradoxical embolism.4 Subsequent closure of the fenestration using different transcatheter devices, such as double umbrellas5-7 and coils8 has been described. We describe our experience with occlusion of a fenestration using the Amplatzer septal occluder device, a procedure done for the first time in the Islamic Republic of Iran. fenestrated Fontan operation ■amplatzer septal occluder device ■ tricuspid valvar atresia 142 M. Esmaeilzadeh, MD, A. Zoroufian, MD and M. Momtahen,* MD I solated ventricular non-compaction is a rare congenital cardiomyopathy, manifested morphologically as prominent myocardial trabeculations and deep recesses that communicate with the ventricular cavity. Heart failure is the most common presenting condition. This report is illustrative of isolated ventricular noncompaction in a 51-year-old male. The diagnosis was made when he presented with congestive heart failure (Iranian Heart Journal 2006; 7 (1): 60-63). left ventricular cardiomyopathy ■ non-compaction ■ heart failure