7 Bahar 1386 Spring 2007 8 1 36 A.A. Amirghofran MD Acute pulmonary embolism is a serious condition and despite diagnostic and therapeutic advances, mortality is still high. Anticoagulation, thrombolytic therapy, catheter embolectomy and open pulmonary embolectomy are therapeutic options. Surgical embolectomy was considered the management of last resort, but recent studies have shown the effectiveness of this therapeutic modality. We reviewed our 7-year experience with pulmonary embolectomy in patients with acute massive pulmonary embolism from 1997 to 2004. Eleven patients underwent open embolectomy. Seven (63.6%) were male and the average age was 45.6. In 5 patients (45.4%), pulmonary embolism occurred after major surgery. Two patients were diagnosed with malignancy and spinal cord injury. No risk factor was detected in 4 patients. The diagnosis was made by spiral CT scan alone in 4 and by angiography in 7 patients. Cardiac arrest occurred in 3 patients pre-operatively. Two patients survived after pre-operative cardiac arrest. Open pulmonary embolectomy is the most effective method of treatment of acute massive pulmonary embolism. CT scan is the best diagnostic modality and cardiac arrest is the worst prognostic factor. Less aggressive clot evacuation in patients who are diagnosed late seems to be effective in minimizing post-operative hemoptysis (Iranian Heart Journal 2007; 8 (1): 6-12). massive pulmonary embolism ■ hemoptysis■ surgical embolectomy 37 Z. Ojaghi MD, A. Moaref MD, F. Noohi MD, M. Maleki MD and A. Mohebbi MD Decreased right ventricular function is a suggested echocardiographic finding after coronary artery bypass grafting (CABG). However, the assessment of RV function is still technically difficult because of the complicated geometry of the RV. The significance and time course of RV dysfunction and its relation to left ventricular ejection fraction and pump time have not been elucidated, however. In this prospective study, we assessed RV function measured from echocardiographic tricuspid annular plane systolic excursion (TAPSE), myocardial systolic velocity and timing interval determined by Doppler tissue imaging (Sm), and myocardial performance index (tei index) obtained from cardiac time interval analysis. In 30 patients accepted for CABG, a baseline echocardiography was done before operation, followed by repeated echocardiograms one week and one month after CABG. RV function was assessed using the magnitude of TAPSE, peak Sm measured at lateral tricuspid annulus and myocardial performance index defined as the sum of isovolumic contraction and relaxation time divided by ejection time. Also the time interval from the Q point of the electrocardiogram to the beginning of the tricuspid annular Sm and Em waves of tissue Doppler imaging was measured before and after operation. TAPSE and peak Sm velocity was significantly reduced one week after CABG (2.34 vs. 1.53 cm, 12.67 vs. 8.5 cm/s, p<0.001) and remained so after one month(1.65 cm, 8.9 cm/s). RV myocardial performance index (tei index) was significantly increased one week after CABG (0.35 vs. 0.78, p<0.001) and remained unchanged one month postoperatively (0.86). There was no significant difference in Q-S and Q-E intervals before and after CABG (89 vs. 92 ms, 433 vs. 411 ms). RV function is significantly reduced after CABG and remained so after one month. The severity of RV dysfunction seems to be correlated with LVEF, duration of CPB time and extent of CAD (more severe postoperative RV dysfunction in patients with 3VD compared to 1VD or 2VD). There is no correlation between postoperative RV dysfunction and the number of grafts performed and RCA lesions (Iranian Heart Journal 2007; 8 (1): 13-19). right ventricle ■ coronary artery bypass graft ■ dysfunction ■ echocardiography 38 A.A. Dadgar MD, M.M. Shabestari MD, S.H. Danesh Sani MD, and L. Alizadeh MD This study was performed to determine whether absence of initial septal q waves in ECG leads correlates with significant (more than 50%) stenosis in the proximal left anterior descending (LAD) coronary artery. One hundred seventy patients who were referred to the catheterization department for coronary angiography were chosen randomly. All the cases had a standard twelve-lead ECG before angiography. According to their ECG, they were divided into two groups: group A: 69 cases who did not have septal q wave and group B: 101 cases who had q waves. Forty-one patients in group A and 14 patients in group B had significant lesions in the proximal LAD ( P value 0.001 and 0.05). Statistical analysis showed that in group A, significant lesion in the proximal LAD could be predicted with 51.9% sensitivity and 62.2% specificity Absence of a normal q wave in the ECG of patients selected for coronary angiography could be a reliable predictor of a significant lesion in the proximal LAD coronary artery (Iranian Heart Journal 2007; 8 (1): 20-23). Q wave■ coronary artery disease■ left anterior descending ■ predictors 39 Paridokht Nakhostin Davari MD, Mahboobeh Dalir-Rooyfard MD and Zahra Ojaghi Haghighi MD In the evaluation of the severity of aortic valve stenosis with echocardiography or catheterization, ventricular function seems to have an impact on the estimation of preferential non-invasive procedure of echocardiography. Fifty-seven patients, who had valvar aortic stenosis without any left heart lesion or ventricular septal defect, were referred to our department for an examination. Mean pressure gradient and indexed aortic valve area (to body surface area) based on the continuity equation, and ejection fraction ratio to peak and mean velocities and pressure gradients across the aortic valve (“function-corrected” indices) were calculated by echocardiography and were compared with one another. The patients were subsequently classified into four groups based on their ejection fraction, and the calculations were done in each group again. In the two groups of ejection fraction less than 65% and more than 85%, the inadequacy in the number of cases precluded a judgment. In the group of ejection fraction between 65% and 75%, there were good correlations between mean gradients and the ratios and good correlation between indexed aortic valve area and the ratios to velocities, but not pressure gradients. In the group of ejection fraction between 75% and 85%, there were good correlations between all of those variables. In the intermediate spectra of the ejection fraction and consequently ventricular function, there were no differences between “function-corrected” indices and previous estimations of mean gradients and aortic valve areas. There is, however, need for further studies with larger numbers of patients to evaluate the correlation of the “function–corrected” indices with mean gradients and aortic valve areas in the upper and lower limits of ejection fraction (Iranian Heart Journal 2007; 8 (1): 24-29). aortic valve stenosis ■ ejection fraction ■ pressure gradient ■ valve area■ echocardiograph Two–dimensional and Doppler echocardiography are current and non-invasive methods for defining the anatomy and the hemodynamic severity of aortic valve stenosis. 40 S. H. Hakim MD, J. Samadikhah MD, A. Alizadeh Asl MD and R. Azarfarin MD - The aim of this study was to determine whether characteristics, presentation and outcome differences based on the patient's gender occur after acute myocardial infarction (AMI). By this prospective multivariate study; we assessed 500 consecutive first infarct survivors (353 men and 147 women), who were admitted to our heart center over a period of 2 years. On average, women were 6.2 years older than men (P=0.030). According to multivariate analysis women were less likely than men to be smokers (p=0.0001) and more likely to have underlying hypertension (P=0.02), diabetes (P=0.041), previous angina (P=0.041), non-Qwave infarctions (P=0.019) and left ventricular ejection fraction < 40% (P=0.038). Men had significantly more 3-vessel coronary artery disease [relative risk (RR) = 1.8, 95% CI, (1.21- 2.38), P=0.02]. In-hospital mortality rate was 19% for women and 12% for men [RR =1.51, 95% CI (0.95-1.82), P=0.044); in addition, the mortality rate at 1-year follow-up was 27% for women and 15% for men [RR=1.61, 95% CI (1.04-2.51), P=0.039]. However, after an agematched analysis, we found no significant differences between men and women for in-hospital mortality. Also, our 1-year follow-up showed that the mortality rate in women was remarkably similar to the age-matched groups in men, but men had more CABG procedures in hospitalization and 1-year follow-up period [RR= 2.34, 95% CI (1.35-3.0), P=0.033]. The age-matched mortality rate in this study was the same for men and women, excluding the greater frequency of 3-vessel involvement, advanced left main coronary disease and greater frequency of CABG operations in men (Iranian Heart Journal 2007; 8 (1): 30-32). acute myocardial infarction ■ gender ■ outcome 41 M. Momtahen MD, F. Farsad PharmD, M. Abbas MD, S. Momtahen MD and A.S. Kazzazi MD This randomized, double blind trial was designed to compare the efficacy and safety of ezetimibe, a new cholesterol-lowering agent with atorvastatin (Lipitor), a potent cholesterolinhibitor derivative. Between September 2004 and March 2005, a total of 120 hyperlipidemic patients, aged 28-80 years, were randomized to receive ezetimibe 10 mg or atorvastatin 10 mg orally daily for 8 weeks after a 4-week washout phase and diet on NCEP step II. Mean changes of serum lipoproteins after 4 and 8 weeks of drug therapy were measured and compared in both groups of patients. Ezetimibe reduced LDLc and total cholesterol by a mean of 27% and 16% compared with 32% and 24% for atorvastatin, respectively. The difference was not statistically significant. Ezetimibe and atorvastatin both reduced LDLc and TC with no statistically significant difference (Iranian Heart Journal 2007; 8 (1): 33-37). ezetimibe ■ atorvastatin■ hypercholesterolemia 42 Ali Sadeghpour Tabaee MD and Bahador Baharestani MD Over 95% of true left ventricular aneurysms result from coronary artery disease and myocardial infarction. The incidence of left ventricular aneurysm in patients suffering myocardial infarction has varied between 10-35%. Large left ventricular aneurysm can cause arrhythmias, congestive heart failure, recurrent myocardial infarction, thromboembolic events and sudden death and operation is indicated for symptomatic large left ventricular aneurysms. In this study we evaluated results of surgical repair of left ventricular aneurysms in association with coronary artery bypass graft. In this descriptive, cross-sectional study from September 1997 to March 2005, we had 1894 CABG operations. Concomitant left ventricular aneurysm repair was done in 54 cases. Surgical complications, clinical findings, left ventricular ejection fraction, NYHA classes, morbidity and mortality were evaluated. NYHA classes were reduced from 3±0.7 preoperatively to 1.23±0.4 postoperatively (p<0.05), and left ventricular ejection fraction changed from 23.82±5.72% to 34.12±7.25% (p<0.05). Surgical complications were re-operation for bleeding in 4 cases (7.4%), sternal dehiscence in 1 case (1.8%) and intra-aortic balloon pump insertion for weaning of CPB in 8 cases (14.8%). Mean ICU stay was 3±1.1 days, mean hospital stay was 13±2.3 days; hospital mortality was 1 case (1.8%). During follow up (1-5 years with a mean of 1±04), all patients are alive, free from cardiac events and have good functional classes. Early and mid-term results of CABG with repair of left ventricular aneurysm are excellent with low morbidity and mortality, and we recommend CABG and repair of left ventricular aneurysm in case of large ventricular aneurysm (Iranian Heart Journal 2007; 8 (1): 38-42). left ventricle aneurysm ■ left ventricle function■ psuedoaneurysm■ Dor operation■ coronary artery bypass graft (CABG)■ aneurysmorrhaphy 43 S. Sokhanvar MD and A. Maleki PhD Hyperuricemia is accompanied by many cardiovascular risk factors. However, the relationship between them, especially with acute myocardial infarction has not been confirmed. The aim of this study was to measure the blood uric acid level in myocardial infarction patients, as well as determine the frequency distribution of blood uric acid levels in our subjects according to their sex, age, smoking habit, blood sugar level, blood lipid level and systolic/diastolic blood pressure. The study is a descriptive–analytic research with easy, non–random sampling. The data was extracted from the patients’ files with myocardial infarction in Zanjan Beheshti Hospital in 2001, and analyzed by calculating measures of central tendency and variability. The mean blood uric acid level in men was 8.23mg/dl (SD=2.13; reliability: 14.5-3.5) and 8.23mg/dl in women (SD=2.21; reliability: 14.9-4.5). It had a negative relationship with cholesterol level, but had a positive relationship with age, blood pressure, triglycerides and fasting blood sugar. However, these relations were not meaningful. There was a meaningful relationship between high blood pressure history and hyperuricemia (P=0.0005), as well as a significant difference among age groups regarding blood uric acid level (P=0.024), but this was not significant for women ( P=0.066). There is a meaningful relationship between hyperuricemia, hypertension and advancing age in men, but blood uric acid level has had no relationship with other risk factors (Iranian Heart Journal 2007; 8 (1): 43-45). hyperuricemia ■ cardiovascular risk factors ■ myocardial infarction 44 A. Kocharian 1 MD, M. Izadyar 2 MD, A. Kiani 3 MD and R. Shabanian4 MD Any chronic hypereosinophilic state, including eosinophilic leukemia, reactive eosinophilia and idiopathic hypereosinophilic syndrome may be complicated by the end-organ damaging effects of eosinophilic degranulation, especially cardiac involvement. Several cytogenetic abnormalities that have prognostic and even therapeutic implications, have been described in patients with different variants of eosinophilic syndrome as well as different features of cardiac involvement. Here we describe an 11-year-old boy whose clinical and laboratory data met the criteria for chronic eosinophilic leukemia except for the cytogenetic abnormality of inversion of chromosome 16 that represents the strongest argument for AML-M4EO, despite no significant increase in bone marrow blasts. Intramural thrombi in both ventricles, mitral and tricuspid valve regurgitation and congestive heart failure were pathologic cardiac findings in our patient. Cytogenetic and molecular genetic analysis is deemed necessary for determining the definite diagnosis, prognosis and therapeutic strategies (Iranian Heart Journal 2007; 8 (1): 46-51). cardiac complications■ endomyocarditis ■ intracardiac thrombi■ eosinophilia ■ chromosome 16 45 Mohsen Horri MD and Rahim Vakili MD* We describe a case of Noonan syndrome referred to the department of pediatric cardiology for routine evaluation of cardiovascular abnormalities. Physical examination, electrocardiogram, chest X-ray and echocardiographic finding confirmed severe hypertrophic cardiomyopathy in the absence of any other cardiac abnormalities or systemic condition (Iranian Heart Journal 2007; 8 (1): 52- 54). Noonan syndrome■ hypertrophic cardiomyopathy 46 H. A. Basiri MD, S. Abdi MD, M. Madani MD, N. Givtaj MD, N. Samiei MD, M., Motavalli MD, H.R. Salehi MD circulation. It can originate from any of the three major coronary arteries and drain in all the cardiac chambers and great vessels. A 28 year-old woman was referred for correction of patent ductus arteriosus. She reported history of few episodes of dyspnea on exertion since several years ago. On physical examination a continuous murmur could be heard mainly at the lower left sternal border. Transesophageal echocardiogrphy showed dilated origin of left main and left circumflex arteries with a continuous flow to the right atrium. Spiral CT coronary angiography revealed an aneurysmal left circumflex artery connecting with the right ventricle. Left system seemed to be dominant. Surgery was done in order to excise the distal part of LCX (Iranian Heart Journal 2007; 8 (1): 55-57). Coronary Fistula■ Color Flow Doppler■ Ventricl 47 M. M. Peighambari MD, A. Shahmohammadi Mousavi MD, M. Madani MD, N. Zafaranloo MD* and L. Zahedi MD* Lipid-lowering therapy with statin reduces the risk of cardiovascular events in acute coronary syndrome (ACS). Preclinical and clinical evidence also indicates that in addition to its lipid-lowering effects, statin may reduce inflammation improve endothelial function and increase plaque stability. We enrolled 220 patients who had been hospitalized for an acute coronary syndrome (unstable angina, non-ST elevation MI) within the preceding 30 days and compared 20 mg of simvastatin daily (group B) with patients not receiving that (group A). The primary end point was a composite of deaths, myocardial infarction, documented unstable angina requiring re-hospitalization, and urgent revascularization (performed at least 30 days after randomization). Follow-up lasted for one month Median LDL cholesterol level achieved during treatment was similar; 90 mg/dl in group B and 87.1 mg/dl in group A (P> 0.05). Chi-square and t-test estimates of the rate of the documented unstable angina requiring hospitalization were 26.4 percent in group B and 31 percent in group A (odds ratio= 4.5; 95% CI= 2.4-6; P= 0.01). Revascularization and early angiography was 20.9 percent in group B and 48.2 percent in group A (odds ratio= 3.5; 95% CI= 1.9-6.3; P< 0.001). Group B had a lower risk of myocardial infarction after admission due to acute coronary syndrome (odds ratio= 4; 95% CI= 1.1-6; P<0.001), reflecting a reduction in mortality (0.9% in group B and 2.7% in group A), but this difference was not significant (P= 0.6), at least partially because of the relatively small number of mortalities in this study (1.8%). Early use of simvastatin in ACS appears to decrease risk for cardiovascular events. We believe statin therapy should be initiated early (at the latest before hospital discharge) in all patients who have been hospitalized for acute coronary syndrome (Iranian Heart Journal 2007; 8 (2): 6-15). acute coronary syndrome ■ blood lipids ■ statins ■ mortality ■ morbidity