14 Zemestan 1386 Winter 2007 8 4 48 M. Hasan Kalantar Motamedi MD, Ali Hemmat MD† and Pooya Kalani MD‡ Background- Rheumatic heart disease and consequent disease of heart valves continues to place a heavy burden on health services providers, especially in developing countries. The ideal heart valve substitute has yet to be found, and new valve designs with innovative processing technologies are being introduced. In this regard, the new Sorin Freedom Solo bovine pericardial valve is designed for supra-annular implantation, is stent-less and without a fabric sewing cuff, and is implanted with a single suture line technique. In this report, we present our initial experience with these substitutes. Between October 2006 and March 2007, nine patients underwent surgery for aortic valve replacement with this biological prosthesis. Seven patients had aortic insufficiency (AI); one, stenosis (AS); three combined, AS/AI; the mean patient age was 53.11±17.54. Standard median sternotomy incision and cardiopulmonary bypass with mild hypothermia was used for all patients. Postoperative results, morbidity and mortality were assessed and hemodynamic data were obtained by echocardiography (mean and peak gradients, valve function) at follow-up. All patients survived the procedure and were discharged from hospital. Mean duration of cardiopulmonary bypass was 92.44±24.65 minutes and mean cross-clamp time was 72.44±16.75 minutes. Mean time of intensive care unit stay was 3.44±1.66 days. Mean and peak transvalvular gradients were 6.5±2.88 mmHg and 17.50±5.68mmHg, respectively at followup (about 8 months). Four patients had trivial AI and there were no paravalvular leakages. All patients are alive and well at the time of this writing and no patient is taking anticoagulants. Our initial experience with the new generation pericardial stentless aortic valve, Freedom Solo, appears to be a promising aortic valve substitute for patients requiring aortic valve replacement. Long-term durability and performance remain to be determined (Iranian Heart Journal 2007; 8 (4): 6-10). aortic valve replacement ■ bioprosthetic heart valve ■ bovine pericardium 49 R. Azarfarin MD, R. Parvizi MD and S. Hassanzadeh Salmasi PhD The recommended dose of aprotinin [3-6 million kallikrein inhibitor units (KIU)] reduces the rate of bleeding after open heart surgery and the need for the transfusion of blood products. However, issues have been raised due to the cost and some side effects of aprotinin, and the use of low doses has been noticed. Various studies have demonstrated the effectiveness of two million KIU doses, whereas there is controversy over one million KIU doses. The purpose ofthis study was to assess the effect of one million KIU aprotinin on bleeding and the need for transfusion after cardiac surgery. A double-blind randomized clinical trial was conducted on 162 coronary artery bypass grafting (CABG) and valve surgery patients from April 2004 to December 2005. The patients were randomly divided into two groups of 81 individuals. In the aprotinin group, 0.5 million KIU aprotinin was infused before and again during cardiopulmonary bypass (CPB); and in the placebo group, 100 ml normal saline (NS) was infused before and during CPB. The need for the use of fresh frozen plasma (FFP) and packed red blood cells (pRBCs) transfusion during and after surgery and the amount of chest tube drainage at 6,12 and 24 hours after surgery were measured in the two groups. The mediastinal and pleural drainage at 6 hours after surgery was 190±24 ml in the aprotinin group and 266±33 ml in the placebo group (p=0.066). The amount of bleeding at 12 and 24 hours was significantly different between the two groups (p=0.048 and p=0.009, respectively). The frequency of blood product transfusion in the aprotinin group was 68% and in the placebo group was 75% (p=0.02). The number of pRBCs and FFP units transfused was significantly lower in the aprotinin group (p=0.000) and p=0.005, respectively). The total amount of blood and products transfusion in the aprotinin group was 2.56 ± 0.27 units and in the placebo group it was 4.37± 0.27 units (p=0.0001). The results indicate that the use of one million KIU of aprotinin (ultra-low dose) in adult cardiac surgery is effective in reducing postoperative bleeding and transfusion requirements (Iranian Heart Journal 2007; 8 (4): 11-16). cardiac surgery ■ blood transfusion■ aprotinin 50 Afshin Foroutan MD, Forouzan Yazdanian MD, Abdollah Panahipour MD, S. Mahmoud Meraji MD, Nader Givtaj MD and Alireza Jafari MD Although midazolam and ketamine are widely administrated as oral premedications for children, only a few studies have investigated the cardiovascular, respiratory and sedative effects of these drugs in children with congenital heart disease (CHD). We compared three methods of administering midazolam and ketamine and a combination of these two drugs as an oral premedication in 165 children with CHD, ASA class II-III, aged 2-8 years, and candidates for cardiac surgery. In this prospective, randomized double-blinded study, we examined hemodynamics, respiratory rate, hemoglobin oxygen saturation, degree of sedation, adverse events such as nausea, vomiting, hallucinations and finally face-mask acceptance or IV line insertion reaction at induction time in three groups. Patients received midazolam 0.5 mg/kg, ketamine 6 mg/kg, or midazolam 0.25 mg/kg plus ketamine 3 mg/kg, 45 minutes before the induction of anesthesia. Heart rate, respiratory rate and hemoglobin oxygen saturation were stable in all three groups. However, systolic and diastolic blood pressure were significantly higher in the ketamine group than those in the other two groups (p=0.001). Sedation score was gradually increased in all the groups, with maximum rate after 45 minutes. After 30 minutes, the midazolam+ketamine group had significantly higher sedation than the other groups (p=0.04). All patients in the three groups had satisfactory separation from their parents. At the time of induction, the cooperation score for face mask acceptance was 81 to 84% among the groups, with no significant differences. However, cooperation at IV line insertion time in the ketamine and the midazolam+ketamine groups (23%, 24%) was better than that in the midazolam group (12%, p=0.03).There were six episodes of emesis in the ketamine group and one episode of nausea in the midazolam+ketamine group. Midazolam and ketamine alone or as a mixed combination are safe oral premedicants in children with CHD undergoing cardiac surgery (Iranian Heart Journal 2007; 8 (4): 17-23). premedication ■ pediatric cardiac surgery ■ congenital heart disease 51 Reza Miri MD, Arash Rashidi MD* and Hamid Akbarshahi, MD The standard 12-lead electrocardiogram (ECG) has relatively low sensitivity for the diagnosis of posterior wall acute myocardial infarction (AMI). The prevalence of posteriorwall myocardial infarction (MI) has been studied in a few studies. We evaluated ST-segment elevation (STE) prevalence in posterior leads in patients with acute coronary syndrome (ACS) in order to determine the prevalence of posterior wall MI and the value of posterior ECG leads in diagnosing it. Patients who were admitted with ACS during a 12-month period to our department were included in the study. Posterior electrocardiogram (V7-V9) was obtained in addition to the standard 12-lead electrocardiogram in the emergency room (ER) and also in the cardiac care unit (CCU). All ECGs were reviewed by a cardiologist for the presence of STE of at least 0.5 mm in two or more leads of V7-V9. In total, 230 patients were diagnosed with AMI based on the World Health Organization criteria, out of 506 patients who were admitted with ACS. In addition, 146 patients (63.47%) had criteria of STE MI in 12-lead standard ECG and 84 patients (36.52%) had non-STE myocardial infarction on standard ECG. Five patients (6%, 95% CI; 2-13.3%) had STE in posterior leads without STE in the standard 12-lead ECG and initially were diagnosed as non- STE myocardial infarction. Overall, 31 patients (13.5%, 95% CI; 9.3-18.6%) had posterior STE myocardial infarction in 15-lead ECG, of which 18 cases (58.1%, 95% CI; 39.1-75.5%) were accompanied with inferior MI, 3 cases (9.7%, 95% CI; 2-25.8%) with anterior MI and 5 cases (16.1%, 95% CI; 5.5-33.7%) with anteroseptal MI in the standard ECG The diagnosis of isolated posterior MI or posterior MI in the presence of other myocardial wall infarction is a challenging diagnosis. These patients may have normal standard ECGs. Obtaining posterior leads will lead to the diagnosis of posterior wall STE MI in a significant number of patients (Iranian Heart Journal 2007; 8 (4): 24-28) myocardial infarction ■ electrocardiography ■ posterior leads 52 H. Farshidi MD, M. Nikparvar MD, S. Abedini MSc, D. Saed MD Smoking remains the single most important modifiable risk factor for cardiovascular disease and also the leading preventable cause of death. There have been a good many studes on the association between demographic variables and smoking rate in urban areas; however, very little has been done in rural areas. This cross-sectional study was conducted on 1375 individuals randomly selected from those residing in the villages of Bandar Abbas. Data were collected by questionnaires and were analyzed by SPSS-11. 55.5 percent of the study group were female. Twenty-two percent were single and 74 percent were married. Eighty percent of them had some level of education up to high school. 15 percent had history of cigarette smoking and 22 percent had history of hobble use. Fortytwo percent of those who had history of cigarette smoking consumed more than 10 cigarettes per day. Smoking was significantly more prevalent among males, married and loweducational subjects. The smoking rate increased with the increase in age up to 40 years old in the total population and the male subgroup, but there was no association between age and smoking rate in the females. The hookah consumption rate was significantly more prevalent in the females and married individuals with low educational status and older age groups. This association was significant in the male and female subgroups, but hookah consumption rate decreased after 60 years of age in the males. According to this study the most important modifiable demographic factor for smoking rate was low educational status, therefore increasing the educational status in rural areas can decrease smoking rate and also cardiovascular diseases in the rural population (Iranian Heart Journal 2007; 8 (4):29 -34). demographic variables ■ smoking rate ■ rural cultures 53 H. Farshidi MD, M. Nikparvar MD, S. Abedini MSc, D. Saed MD Smoking remains the single most important modifiable risk factor for cardiovascular disease and also the leading preventable cause of death. There have been a good many studes on the association between demographic variables and smoking rate in urban areas; however, very little has been done in rural areas. This cross-sectional study was conducted on 1375 individuals randomly selected from those residing in the villages of Bandar Abbas. Data were collected by questionnaires and were analyzed by SPSS-11. 55.5 percent of the study group were female. Twenty-two percent were single and 74 percent were married. Eighty percent of them had some level of education up to high school. 15 percent had history of cigarette smoking and 22 percent had history of hobble use. Fortytwo percent of those who had history of cigarette smoking consumed more than 10 cigarettes per day. Smoking was significantly more prevalent among males, married and loweducational subjects. The smoking rate increased with the increase in age up to 40 years old in the total population and the male subgroup, but there was no association between age and smoking rate in the females. The hookah consumption rate was significantly more prevalent in the females and married individuals with low educational status and older age groups. This association was significant in the male and female subgroups, but hookah consumption rate decreased after 60 years of age in the males. According to this study the most important modifiable demographic factor for smoking rate was low educational status, therefore increasing the educational status in rural areas can decrease smoking rate and also cardiovascular diseases in the rural population (Iranian Heart Journal 2007; 8 (4):29 -34). demographic variables ■ smoking rate ■ rural cultures 54 Feridoun Noohi MD, FACC, Maryam Esmaeilzadeh MD, FCAPSC, Maryam Moshkani Farahani, MD, Anita Sadeghpour MD, FASE, S. Zahra Ojaghi MD, Niloofar Samiei MD Non-compaction of ventricular myocardium (LVNC), also known as LVHT (left ventricular hypertrabeculation), is a rare embryonic cardiomyopathy that is thought to be a consequence of intrauterine arrest of compaction. It is characterized by an excessively prominent trabecular meshwork, which is accompanied by depressed ventricular function, systemic embolism and ventricular arrhythmia. This study was conducted to clarify the clinical features of patients with left ventricular noncompaction (LVNC) who were diagnosed in Shahid Rajaei Cardiovascular Medical Center. We retrospectively reviewed patients with LVNC between December 2004 and December 2005. A total of twenty-four patients were identified. In 4 patients there were associated cardiac lesions. They consisted of 6 females and 18 males with a mean age of 38.2 years (age range: 13-62 years). The average ejection fraction was 23.3%.The extension of noncompacted myocardium that was observed on 2-D echocardiography, was predominantly at the apex. There were two patients with systemic emboli, one with nonsustained ventricular tachycardia (VT), and one with Wolf-Parkinson-White sydnrome. The most common abnormality in the the electrocardiogram was left bundle branch block. LVNC is most frequently diagnosed primarily by echocardiography and its prevalence seems to be increased with the improvement of cardiac imaging; so echocardiographers should be aware and trained to recognize this abnormality (Iranian Heart Journal 2007; 8 (4): 35-42). Non-compaction ■ left ventricle ■ cardiomyopathy ■ heart failure 55 Mohsen Gharakhani MD* and Marzieh Farimani MD** Coronary artery disease (CAD) is the second cause of mortality in women over the age of 40. The risk factors for CAD in females include: age over 55, BP>140/90, smoking and hyperlipidemia. As we know, the plasma lipoprotein level changes significantly during pregnancy, and low density lipoprotein reaches its peak approximately in the 36th week of pregnancy. Hypercholesterolemia induced by pregnancy may be atherogenic. The purpose of this study was to evaluate any relation between multiparity and CAD. In this case-control study, 230 women over 50 years old were studied. Of this total, 115 were considered as the case group, who were selected from among patients with CAD admitted to the cardiac ward. Another 115 patients without CAD who were admitted to the internal and surgery wards with normal cardiovascular consultation were selected as the control group. Patients with known risk factors such as hypertension, hyperlipidemia, diabetes, obesity, active and passive smokers, type A personality and any record of hormone replacement therapy were excuded. The data were analyzed using the commericially available software package SPSS, version 11. Student ׳ s t-test and χ2 were used for analysis, and results were expressed as mean ± SD. p value <0.05 was considered statistically significant. The mean age of the subjects at first parity in the case and control groups was 16.09±2 and 16.3±2 years, respectively (p=NS). The mean number of parities in the case group was 7.5±3.1, and 5.9±1.9 in the control group (p<0.001). Body mass index (MI) was 23.6 and 24.8, respectively; and mean cholesterol level, LDL and HDL in the case and control groups were within normal limits, with no patients being overweight. The average cholesterol, HDL, and LDL levels for the case and control groups were 164.2 vs. 164.1, 102.6 vs. 105.4 and 34.5 vs. 40.5, respectively. Exposure to repeated periods of hyperlipidemia induced by pregnancy may be responsible for an increased risk of CAD, especially in women with parity above four. The patient’s age at first pregnancy was not observed to be a risk factor for CAD(Iranian Heart Journal 2007; 8 (4): 43-46). coronary artery disease ■ parity ■ risk factor 56 Mohammad Agaei Shahsavari MD,ã Masood Noroozian MD,ã Pegah Veisi MD,ã Raziye Parizad, MSc,ãã and Jahanbakhsh Samadikhah MDããã We aimed to assess the magnitude of the problem of cardiovascular risk factors in hospitalized patients and to establish cardiovascular disease (CVD) risk factor profiles. We selected 476 confirmed CVD patients by a multi-stage stratified cluster random sampling technique in Tabriz Heart Center. After obtaining demographic information and performing physical examination, we measured biochemical parameters. Data were analyzed with SPSS 10.05, and p<0.05 was considered significant. Obesity was the most common abnormality (93.5%), followed by diabetes mellitus (58.4%), low levels of high-density lipoprotein cholesterol (HDL-c) (45.4%), low physical activity (41.6%), high total cholesterol (TC) (40.1%), high triglycerides (TG) (37.2%), high low-density lipoprotein cholesterol (LDL-c) (30.7%), diastolic hypertension (28.4%), high systolic blood pressure (24.8%) and smoking (20%). Ninety-three percent, 43%, 16% and 5% of patients had one, two, three and four risk factors for CVD, respectively. The prevalence of lipid disorders in females was more than that in males, except for low HDL-c (p<0.05). Among the lipid profiles, only TG had a relationship with age (p<0.05). Obesity was accompanied by lipid profile abnormality, such that low serum levels of HDL-c and high levels of TG, TC and LDL-c were more common in obese patients (p<0.05). This study revealed a high prevalence of risk factors in the CVD patients; thus modification of lifestyles is urgently needed (Iranian Heart Journal 2007; 8 (4): 47-52). HDL-c ■ LDL-c ■ TC■ TG ■ age ■ gender ■ BMI ■ cardiovascular disease 57 B. Parsi MD, PhD*, A. Mohseni MD** and R. A. Mohammadpour PhD*** Obesity is introduced as a known risk factor of coronary artery disease (CAD) by the American Heart Association. Body mass index (BMI) is an index used for the evaluation of body weight. Despite the presence of the relationship between BMI and occurrence of coronary artery disease, no relationship has been found between the degree of coronary artery obstruction and BMI, which is the main issue of this research. In order to determine BMI at different stages of coronary artery obstruction, this descriptive study was done on 215 patients referred to the angiography unit and BMI was measured at different stages of coronary artery obstruction. Questionnaires containing demographic features and risk factors of CAD were completed. The obtained data were analyzed using SPSS software and descriptive analysis tests. Of 215 patients under study with a mean age of 55 years (83 men and 132 women), all of them suffered from coronary artery problems ranging from one-vessel disease to complete obstruction. The severity of coronary artery obstructions and the number of vessels involved had a direct relationship with an increase in BMI. There was a significant relationship between the degree of BMI and observation of severity in obstruction during angiography (p<0.005). Considering the aim of this study and the main finding, which is the presence of a significant relationship between the degree and severity of coronary obstruction with BMI and since BMI is known as a coronary artery disease risk factor, BMI can be named as a predictor of the severity of obstruction. Further studies are, however, required (Iranian Heart Journal 2007; 8 (4): 53-56). body mass index ■ coronary artery obstruction ■ obesity 58 Anita Sadeghpour, MD, Maryam Moshkani, MD, Saeed Hoseini, MD, Feridoun Noohi MD FACC, Majid Maleki MD We describe a large family in which 13 members over two generations developed aortic dissection or aortic aneurysm at a young age. Two sisters of this family presented with type A aortic dissection within one week with no previous medical history, Marfan’s syndrome or other connective tissue disorders. Their 2D echocardiographic images were unique with floating tissue in the false lumen. Hereditary disorders, familial aortic aneurysms cause the individuals to develop an enlargement of the aorta. The aneurysm may occur anywhere, dilation at the level of the ascending aorta or the sinus of Valsalva, and it may progress over time to eventually tear or rupture. In both of our cases, the intimal flap started from the annulus and extended to the abdominal aorta, with severe aortic regurgitation. The Bentall procedure was performed for both of our patients; one of them died during the operation due to massive hemorrhage, but the other one tolerated surgery well. All their family members were subsequently screened; there was no medical history of Marfan’s syndrome or other connective tissue diseases. Echocardiography, however, showed varying degrees of dilatation of the ascending aorta in most of the first and second-degree relatives with mild to moderate AI, suggestive of familial aortic aneurysms (Iranian Heart Journal 2007; 8 (4): 57-59). aneurysm ■ aorta ■ dissection 59 Mahdi Peighambari MD, Anita Sadeghpour MD, Mahboobeh Dalirrooyfard MD, Homayoon Zaheri MD and Mohammad Ali Yousefnia MD We present a case of aorta-to-left ventricle tunnel and non-compaction of the left ventricle in a female of 26 years of age. She was referred to our echo lab for an evaluation of aortic regurgitation severity, and echocardiography revealed the diagnosis of the congenital abnormality of aorta-to-left ventricle tunnel and non-compaction of the left ventricle (Iranian Heart Journal 2007; 8 (4): 60- 62). non-compaction left ventricle ■ aorta-left ventricle tunnel 60 J. Vahedian MD and A. Sadeghpour MD Phlegmasia cerulea dolens (PCD) is the term describing the painful venous congestion that results from near-total venous occlusion of a limb. Acute symptomatic upper extremity deep vein thrombosis (DVT) is estimated to account for only 2-4% of all DVTs. Upper extremity DVT leading to PCD occurs in an estimated 2-5% of these cases. Progression of PCD to venous gangrene is extremely rare with only a handful of cases reported in the literature. Only a few of the cited cases document significant tissue loss. This report describes a 56-year-old female who developed upper extremity DVT complicated by PCD, which led to venous gangrene and hemorrhagic cerebral stroke and death two weeks after coronary artery bypass graft (CABG) (Iranian Heart Journal 2007; 8 (4): 63-68). upper extremity ■ deep vein thrombosis ■ phlegmasia cerulea dolens ■ venous gangrene ■ CABG ■ subclavian vein thrombosis 61 M. H. Nezafati MD, M. Abbasi MD and G. Soltani MD White-Garland syndrome is a rare congenital lesion. It is the most common congenital coronary artery anomaly (0.26% of patients with congenital heart disease) that results in myocardial ischemia and infarction in children.1 ALCAPA usually presents in infancy when the pulmonary vascular resistance drops in the first few weeks of life.2 Depending on the degree of collateral development, myocardial ischemia or infarction may occur. Since 90% of such patients die during the first year of life,3 ALCAPA is rarely seen and reported in children (Iranian Heart Journal 2007; 8 (4): 69-71). Bland-White- Garland syndrome■ anomalous coronary artery