8 Zemestan 1385 Winter 2006 7 4 101 F. Akbarzadeh MD and R. Parvizi MD Atrial fibrillation is a common arrhythmia in patients with rheumatic mitral and other valve diseases who are candidates for valve repair surgery. Conversion to sinus rhythm has positive effects on quality of life and lowering medication use. The aim of this clinical study was to evaluate the effectiveness of the radiofrequency ablation Maze III procedure in the treatment of atrial fibrillation associated with rheumatic heart valve disease. We applied the modified Cox III Maze procedure with the use of radiofrequency ablation in the treatment of atrial fibrillation associated with rheumatic heart valve disease and evaluated the outcome in 20 patients with atrial fibrillation. Demographic, echocardiographic, electrocardiographic and Doppler study data were calculated before and six months and one year after surgery. No perioperative deaths occurred in the study group. Duration of additional time needed for doing radiofrequency ablation was about 22 minutes. Freedom from atrial fibrillation was 85% and 75% at six months and one-year follow up, respectively. The addition of the radiofrequency ablation Maze procedure to heart valve surgery is safe and effective in the treatment of atrial fibrillation associated with rheumatic heart valve disease (Iranian Heart Journal 2006; 7 (4):6-12). radiofrequency ablation <Maze<atrial fibrillation ■ rheumatic heart valve disease 102 Morteza Safi, MD and Farah Naghashzadeh, MD The primary objective of reperfusion therapies for acute myocardial infarction is not only to restore the blood flow in the epicardial coronary artery but also to complete and sustain the reperfusion of the infarcted part of the myocardium. In this cross-sectional study on 50 patients who underwent primary coronary angioplasty, we assessed the correlation between LV ejection fraction and angiographic evidence of myocardial reperfusion (myocardial blush grade). The myocardial blush grade after the angioplasty procedure was graded by two investigators, who were otherwise blinded to all clinical data. On the 5th day after MI, left ventricular ejection fraction was assessed by 2D echocardiography (Simpson’s method). This study showed that the myocardial blush grade was directly related to the left ventricular function. Ten patients had MBG 0-1, 21 patients had MBG 2, and 19 patients had MBG 3, the mean ejection fraction being 42±12.2 %. Severe LV systolic dysfunction was found in six patients, moderate LV systolic dysfunction in 24 patients, and mild LV systolic dysfunction in 14 patients; and the remaining 6 patients had normal LV function. Multivariate analysis showed that there is a direct correlation between MBG and LV function (R=0.77, p<0.01). In patients after reperfusion therapy, the myocardial blush grade as seen on the coronary angiogram is a predictor of left ventricular function and can be used to describe the effectiveness of the myocardial reperfusion (Iranian Heart Journal 2006; 7 (4):13-16). myocardial blush ■ ejection fraction ■ myocardial infarction coronary angioplasty 103 Farzad Jalali, MD, Seyyed Mohammad Miri, MD* and Pegah Karimi Elizei MD Prolongation of ventricular depolarization time (QRS duration), particularly in left bundle branch block (LBBB), is commonly associated with many cardiac diseases. We posit that the QRS duration and degree of left-axis deviation (LAD) identify significant left ventricular (LV) systolic dysfunction in patients with LBBB. In this prospective study, 150 patients with diagnosis of LBBB were divided into two groups (QRS≥160 and QRS<160 milliseconds). Then the relationships between QRS duration, left axis deviation (LAD: axis between –30° and –90°), and echocardiographic LV ejection fraction (EF) were derived by t-test, chi-square, and linear regression analysis in a step-wise method. There was no significant difference in age and sex among the patients with or without LAD and QRS duration less or more than 160 ms (p>0.05). The EF of patients with LAD (n=64) and without LAD (n=86) was 48.64±14.63% and 52.10±13.98%, respectively (p=0.143). The mean±SD EF (54.5±10.54%) of the patients with a QRS duration of ≥160 milliseconds (n=19) was significantly more than the mean ± SD EF (23.89±5.46%) of the patients with a QRS duration of <160 milliseconds (n=131, p<0.001). The QRS duration also had a significant (p<0.001) inverse correlation with EF (R = 0.926, adjusted R2 = 0.857, SE of estimate = 5.42). However, the QRS axis was not significantly correlated with EF and did not have added predictive values. The QRS duration has a significant inverse relationship with EF. Furthermore, the prolongation of QRS duration (≥160 milliseconds) in the presence of LBBB is a marker of significant left ventricular systolic dysfunction. The presence of LAD in LBBB does not signify a further decrease in EF (Iranian Heart Journal 2006; 7 (4):17-25). QRS duration■ electrical axis■ LV dysfunction■ ejection fraction■ left bundle branch block 104 S. Ghaffari MD and J. Samadikhah MD. Right ventricular infarction (RVI) is a common complication of inferior wall infarction and usually leads to a greater mortality and in-hospital complications. This study aims to evaluate the value of TIMI risk score in the prediction of in-hospital and long-term mortality in RV infarction. Five hundred patients with acute inferior infarction were surveyed in this study. Inhospital complications and mortality of these patients were collected, and they were followed on average for about 31 months. RVI was diagnosed in 24% of the patients. In-hospital morbidity (RVI: 56.7% vs. non- RVI: 34.4%; P<0·001) and mortality (RVI: 28.3% vs. non-RVI: 8.9%; P<0.001) were increased in patients with RVI. Any one-point increase in TIMI risk score led to a 3.5±1.4 percent increase in in-hospital mortality (P=0.001). Long-term mortality, however, did not reveal such a correlation with TIMI risk score (P=0.1). Out-of-hospital mortality in a mean follow-up period of about 31±8.7 months was 24.3% in the RVI and 12.1% in the non-RVI group (p=0.02). RV infarction significantly increases in-hospital complications and mortality of inferior infarction. Any one-point increase in TIMI risk score leads to a parallel increase of inhospital mortality but there is no such a correlation between TIMI risk score and long-term mortality (Iranian Heart Journal 2006; 7 (4):26-30). myocardial infarction n right ventricular infarction n TIMI risk score n prognosis 105 A. Ali Rafighdoost MD, M. Shabestari MD, and T. Bostani MD Hypertension is the most prevalent controllable lethal disease in the present century and is one of the most common causes of visits in private offices and general clinics.1,2 In our region, no extensive study has been done on the incidence and precipitating factors of hypertensive crisis in patients with primary hypertension. Given the very large number of patients referring for this reason to Mashhad and especially in Imam Reza (A.S.) Hospitals, this study was conducted with the aim of determining the incidence of hypertensive crisis and its precipitating causes and proposing plans to control these factors. A prospective study was done on hypertensive patients referring for hypertensive crisis in the cardiac emergency room of Imam Reza (A.S.) Hospital during an 18-month period from August 2002 to March 2004. By definition, a diastolic blood pressure of 140 mmHg or higher was set for choosing patients, and on this basis 192 patients entered the study. Study subjects were selected from patients aged 30 to 75 years, and an effort was made to ensure that all the subjects had primary hypertension. Among the 192 patients, males comprised the higher percentage. Hypertensive crisis occurred most commonly in patients aged 50 to 60 years, followed by those above 70. 75% of the patients had stopped taking medications for a long time, and the most common reasons for this were a feeling of improvement, growing tired of the long-run medications, being on a journey with the drugs left at home, and side effects, respectively. This study proved emotional stress and diet changes, especially taking excess salt, as important precipitating factors. Hypertension is an important threat to general health in the developed countries, and has the characteristics of being common, asymptomatic, and easily detectable and treatable. A potentially fatal complication of hypertension is hypertensive crisis. This study was conducted with the aim of determining the incidence and the causes of hypertensive crisis and proposing ways to prevent its occurrence. It is recommended that the drugs should be taken life-long and not stopped without doctor’s permission. The patients should be careful to take along their medications on trips and to continue to observe a low-salt diet (Iranian Heart Journal 2006; 7 (4):31-36). hypertensive crisis■ primary hypertension■ stress ■ anti-hypertensive drugs 106 Mahdi Moosavi MD, Ebrahim Nematipour MD and Maryam Mehrpooya MD Type 2 diabetes mellitus is associated with an increased prevalence of atherosclerosis and coronary heart disease. This study was performed to determine the severity and extent of coronary artery disease in diabetics compared to non-diabetics. Fifty type 2 diabetic patients and 50 sex- and age-matched non-diabetics, who were candidates for angiography to diagnose coronary artery disease, were enrolled in the study. Those patients with valvular heart disease, congenital heart disease and rhythm disturbances were excluded from the study. Selective angiography was performed, and a single experienced observer reported the angiograms and Gensini scores were calculated to determine the severity of the atherosclerosis. Sixty males and 40 females were included in the study, with a mean age of 57.3±8.4 (Mean ± SD). Diabetic patients had higher Gensini scores than non-diabetics (51.44 ± 44.6 vs. 34.12 ± 29.9, P<0.05). Categorical staging of various types of coronary artery disease significantly differed in diabetic and non-diabetics (P<0.05), and multi-vessel CAD (P<0.05) was seen more often in diabetics. Moreover, mono-vessel CAD (P<0.05) was more common in non-diabetics, but normal coronary arteries did not significantly differ between the two groups. Hyperlipidemia and diabetes were associated with Gensini scores independently (P=0.02 and P=0.04, respectively), and a trend toward a positive association was seen between family history of coronary artery disease and Gensini score (P=0.06), but hypertension and cigarette smoking did not show any significant association. Left main coronary artery disease, disease of the proximal portion of left anterior descending artery, presence of occluded vessels, ejection fraction, left ventricular end diastolic pressure, and catheter-based systolic and diastolic blood pressure were not significantly different between diabetics and non-diabetics. According to our study, diabetics may have more extensive coronary artery disease at presentation, hence care must be taken in the diagnosis and management of these patients, and it is better to maintain a lower threshold for performing noninvasive and sometimes invasive studies for the detection of coronary artery disease in diabetics (Iranian Heart Journal 2006; 7 (4):37-42). Atherosclerosis■ coronary artery disease diabetes 107 M. Y. Aarabi MD, A. Shahmohammadi MD, P. N. Davari MD, M. Meraji MD, A. Tabib MD and H. Mortezaeian MD There are many limitations to the use of conventional echocardiography indices for the estimation of systolic and diastolic left ventricular (LV) function. Anthracycline chemotherapy causes myocardial damage, leading to acute or chronic congestive heart failure during or soon after treatment in a significant percentage of patients treated, depending on the total cumulative dose used. The aim of this study was to determine the usefulness of myocardial performance index (MPI) in evaluation of subclinical cardiotoxicity in patients undergoing chemotherapy with anthracyclines. Seventy-five patients (41 male, 34 female, mean age 9±3 years) with malignant solid tumors and hematologic malignancy were randomly selected and evaluated before, during and after therapy by 2-D, M-Mode and Doppler echocardiography; and the data were compared with 48 age- and sex-matched normal controls prospectively. Twenty-three patients were taking high doses of anthracyclines (>200mg/m2), whereas 52 patients were taking low doses of anthracyclines (<200mg/m2). Mean dose of anthracyclines in all the patients was 140±60mg/m2. IVCT was prolonged (42±11msec vs. 28±8msec, P-value=0.018) compared with normal control subjects. ET was shortened (220±24msec vs. 234±14msec, Pvalue= 0.025), and MPI was increased in the anthracycline-treated patients compared with normal control subjects (0.44±0.06 vs. 0.34±0.04, P-value =0.015). Also, we found no correlation between MPI and cumulative dose of anthracyclines in 52 patients taking lower doses (<200mg/m2) compared with 23 patients taking higher doses (>200mg/m2); MPI was 0.42±0.04 vs. 0.44±0.08, with P-value =0.062 between the two groups. No significant difference was found in LVEF (0.58 ± 0.12 vs. 0.64±0.06, P-value=0.056) and LVFS (0.32±0.08 vs. 0.36±0.04, Pvalue= 0.068) between the patients and normal controls. The findings of this study suggest that anthracycline cardiotoxicity is subtle and subclinical and systolic functions are preserved. MPI is helpful in the discrimination of early cardiac involvement from anthracycline chemotherapy, especially in asymptomatic young patients with normal limited systolic function. Moreover, MPI can enhance the accuracy of echocardiographic diagnosis in early ventricular dysfunction. Cumulative dose of anthracyclines is not a suitable parameter in the determination of the risk of the severity of anthracycline cardiotoxicity. Recent advantages in diagnostic tests have allowed diagnosis at early stages of disease before massive cell injury and irreversible changes occur (Iranian Heart Journal 2006; 7 (4): 43-48). myocardial performance index (MPI) ■ isovolumic relaxation time (IVRT) ■ isovolumic contraction rime (IVCT) ■ejection time (ET) ■ anthracycline. 108 Mehdy Hasanzadeh Delui MD and Paria Dehghanian, MD Atrial arrhythmias occur frequently after cardiac surgery, and atrial fibrillation (AF) was the most common atrial arrhythmia after cardiac surgery. It occurs in up to 40% of patients primarily within 2 to 3 days, and it can compromise systemic hemodynamics and increase the risk of embolization. Some clinical issues can predict the risk of atrial fibrillation, like P wave duration. The aim of this study is to evaluate the role of P wave duration in prediction of post cardiac surgery AF. We measured P wave duration in 206 cardiac surgery patients the day before surgery and followed the patients for 3 days to find the possible relation between P wave duration and the risk of AF after surgery. Our study showed the prevalence of AF after cardiac surgery was about 9% and there was no relation between P wave duration before surgery and risk of AF after surgery. The risk of AF in our patients was less than other studies, and this study showed we can not use P wave duration in surface ECG as a predictor of post-cardiac surgery AF (Iranian Heart Journal 2006; 7 (4): 49-51). atrial fibrillation ■ cardiac surgery ■ P wave 109 Paridokht Nakhostin Davari MD, Akbar Shahmohammadi MD, M.Yousef Aarabi MD, Mahmoud Meraji MD, and Habibollah Yadollahi Farsani MD One of the most important tools for the evaluation of children's health is determining the systemic arterial blood pressure (SABP), which is affected by weight, gender, stature, and environmental conditions. The variation of children’s SABP is between the 5th and 95th percentile curves. Due to environmental conditions, some criteria may be different in other countries. We measured the SABP of 1000 7-12-year-old students who were selected randomly. The SABP percentile curves are plotted on the basis of weight, stature, and sex; and they will of course be affected by environmental conditions. The results show that the most abundant systolic SABP was 100 mmHg (27%) and the least abundant was 75 mmHg (1%). For diastolic SABP, the highest and lowest prevalences were 65 mmHg (28.2%) and 45 mmHg (0.1%), respectively. The correlation between age (p<0.01), weight, stature, and sex (p<0.005) and the SABP of the children was determined: SABP increased with an increase in age, weight, and stature. In addition, SABP in girls was higher than that in boys in the same situation. In light of our results, it is necessary that children be protected against cardiovascular diseases by laying emphasis on suitable nutrition and exercise in school curriculum (Iranian Heart Journal 2006; 7 (4): 52-56). blood pressure■ children■ percentile curve■ weight ■age■ gender 110 A. Sadeghpour MD, S. Arefi MD,* J. Vahedian MD, K. Raisee MD, N. Givtaj MD, G. Omrani MD, S. Hosseini MD, R. Baghaee MD, B. Baharestani MD, M. Gholampour MD, T. Babaee MD and A.H. Sadeghpour MD We report the case of a patient with a pseudoaneurysm of the ascending aorta. He was referred to our hospital because of chest pain and dyspnea. A preoperative diagnostic evaluation revealed a large pseudoaneurysm of the ascending aorta close to the proximal anastomotic site of the graft. During surgery, the pseudoaneurysm originated from an intimal defect in the aortic wall on the right side of the right coronary artery 1cm proximal to the suture line. Replacement of the ascending aorta was successfully performed (Iranian Heart Journal 2006; 7 (4): 57-60). aortic pseudoaneurysm ■ aortic root replacement ■ Bentall operation ■ ascending aorta aneurysm 111 M. Esmaeilzadeh MD,* A. Tavakolli MD,** M. A. Yousefnia MD,*** and Safaei MD**** Intravenous leiomyomatosis is a histologically benign smooth-muscle tumor arising from either a uterine myoma or the walls of a uterine vessel with extension into veins. We describe echocardiographic features of intravenous leiomyomatosis with spread into the right-sided cardiac chambers. The patient was a middle-aged woman, with prior history of hysterectomy 2 years earlier who presented with cardiac symptoms and signs. Echocardiographic features included: 1) elongated mobile mass extending from the inferior vena cava, and 2) multiple masses in the right-heart chambers (right atrium and ventricle). Intracardiac leiomyomatosis should be considered in a female patient presenting with an extensive mass in the right-sided cardiac chambers (Iranian Heart Journal 2006; 7 (4): 61-66). echocardiography ■ leiomyomatosis ■cardiac tumor 112 Rezayat Parvizi MD, Ahmad Reza Joudati MD, Vahid Montazeri MD, Susan Hassanzadeh Salmasi PhD and Mojtaba Varshouchi, MD Cardiac hydatid cyst is an uncommon disease, its prevalence being about 0.5–2%. 90% of parasites which are digested orally are removed by the liver and lung, 10% enter the general circulation and 1% enters the coronary arteries. Its cause is echinococcus, which is found in animals such as sheep and dogs. The mortality rate of disease is 10.2%. The aim of this study is to present the results of 10 cases with cardiac echinococcosis operated in Shaheed Madani Heart Hospital in Tabriz. From 1992 to 2004, ten cases of hydatid cyst of the heart underwent surgical excision. For collecting data a questionnaire was used and statistical analysis was performed with SPSS software and was done through descriptive statistical method. There were 7 females and 3 males (F/M ratio = 2.3/1). The mean age of patients was 25.6 years old. All patients were operated through median sternotomy with CPB. Surgical treatment included puncture of the cyst and sterilization with hypertonic saline solution and total cyst extirpation. There was one perioperative mortality and one case with cerebral hydatid cyst one year later. All patients received albendazole pre- and postoperatively. Surgical treatment of cardiac hydatid cyst is safe. It is recommended that patients receive mebendazole or albendazole 30-40 mg/kg for 6-24 months postoperatively. Reduction of serum levels or achievement of negative test results indicates positive therapeutic effects (Iranian Heart Journal 2006; 7 (4): 67-71). hydatid cyst ■ cardiac tumor ■cardiac surgery 113 H. Bassiri, MD and S. Abdi, MD T 19 patients with a mean age of 21±12 years with aortic coarctation, 14 native and 5 recoarctations, were treated by stenting in our center over a period of two years. The mean peak systolic pressure gradient across the coarcted segment was 54 mmHg ± 14 mmHg. The procedure was effective in all 19 cases. Immediately after stent implantation the mean peak systolic gradient fell to 6±4 mmHg (P< 0.001). Complications occurred in 2 patients (stent migration in 1, edge dissection in another patient). Stent implantation for aortic coarctation and native coarctation gives good immediate results. Non-invasive studies including spiral CT scan and echocardiographic study is recommended for follow-up after stent implantation in order to evaluate long-term results (Iranian Heart Journal 2006; 7 (3):5-8). coarctation of aorta ■ stent implantation ■ recurrent coarctation of aorta