6 Bahar 1387 Spring 2008 9 1 26 Ali Mohammad Haji Zeinali MD,* Mehrab Marzban MD, Mohammad Reza Zafarghandi MD, Mahmood Shirzad MD, Shapoor Shirani MD, Mohamad Alidoosty MD, Mojtaba Salarifar MD, Ebrahim Nematipour MD, Hamidreza Poorhoseini MD, Ebrahim Kasaian MD, Davood Kazemi Saleh MD, Babak Haghighat MD, and Mansour Arafat MD Endovascular aortic repair (EVAR), as a new and less invasive method for treatment of aortic aneurysms, has shown lower short term complications than routine open surgical repairs. In this report we present our results with the first consecutive series of this technique in our patients. From Dec. 2006, we began a prospective case series of EVAR patients for the first time in Iran, and so far, 15 consecutive patients (1 female, 14 male) with the mean age of 66 years (range 36 to 89 years old) underwent endovascular aortic aneurysm repair (3 thoracic, 11 abdominal, 1 combined thoracic and abdominal) with Medtronic “Talent” or “Valiant” stent grafts. In-hospital and one month follow up results are reported as short-term outcome. All 12 abdominal aorta aneurysms (AAA) were infrarenal with an acceptable proximal neck. In eight patients, associated iliac aneurysms were seen. For 11 AAA patients, routine modular stent grafts were used and in one case, unilateral stent graft was implanted because of difficulty of controlateral stent graft implantation. Four thoracic aorta aneurysms (TAA) were repaired with Valiant stent grafts. One of them was a Marfan patient with recent Bentall surgery and two were post-surgery saccular aneurysms. In all 15 cases, stent graft implantation was done successfully. In five cases, mild type II endoleak was seen at the end of the procedure, which was no longer present on one month follow up. One patient had post- procedure cerebral stroke with delayed mortality. No other major complications were seen in 1 month follow up in the other 14 cases. Minor complications like vascular access hematoma, anemia and increased creatinine were controlled on hospital stay period in some cases. Control CT angiography in some patients revealed no endoleak or aneurysm enlargement and 6 and 12-month follow up assessment will be done for mid-term results. Endovascular repair of aortic aneurysm is feasible and safe for suitable cases based on both clinical and radiologic findings. Good case selection, good device selection and suitable follow up are the keys for success of EVAR (Iranian Heart Journal 2008; 9 (1): 6-13). aortic aneurysm ■ endovascular repair■ stent-graft ■ EVA 27 M. Namdari MD*, M. Ghafarzadeh MD and B. Baharvand MD Peripartum cardiomyopathy is a type of cardiomyopathy found in pregnancy and up to 5 months after delivery. There is no identifiable cause for myocardial dysfunction in these patients. In this study, we evaluated our patients for symptoms, signs, functional class, prognosis and complications. Eighteen pregnant patients with myocardial dysfunction and diagnosis of peripartum cardiomyopathy were evaluated from Dec. 1998 to Dec. 2007. All patients had echocardiography follow up, and symptoms and signs of every patient were evaluated for 5 years. Mean age of patients was 34±5 yrs, mean left ventricular ejection fraction (LVEF) according to echo was 27±5%, and dyspnea was present in 100% of patients. Chest pain was present in 61.11%, arrhythmia in 50%, edema in 72.22% and hypertension in 27.77%. During follow up, there were 22.22% next pregnancies in 5 years. Mortality occurred in 16.66%, remission in 27.77%, partial resolution of symptoms and signs and improved LVEF in 22.22%, and no improvement in 33.33%. Vaginal delivery was performed in 77.77% and cesarean section in 22.22% of patients. Peripartum cardiomyopathy is a lethal disease during pregnancy. We do not recommend allowing next pregnancies and cesarean section is lethal; vaginal delivery is the best method of parturition for these patients (Iranian Heart Journal 2008; 9 (1): 14-17). peripartum cardiomyopathy ■ vaginal delivery ■ cesarean section ■ dilated cardiomyopathy 28 Mohsen Maadani MD, Seifollah Abdi MD and Ali Zahedmehr, MD Percutaneous coronary intervention (PCI) is an invasive procedure which traumatizes the coronary vessel wall and serves as a potent stimulus for thrombus formation. Unfractionated heparin is used routinely during the procedures to reduce the likelihood of acute thrombotic complications. Activated clotting time (ACT) is the preferred assay to determine the degree of anticoagulation during PCI. Our aim was to assess ACT values during PCI after administering heparin with conventional dose (10000 u) and determining ischemic and bleeding complications. Coronary artery disease (CAD) patients (N=205) receiving conventional heparin dose and undergoing PCI were included in this study. ACT was assessed 10 minutes after heparin injection. Demographic data and cardiovascular risk factors were registered in the forms and the patients were followed up for about one month for complications. ACT range 10 minutes after heparin injection was 160 – 682 sec (mean 353 sec, SD: 94.5 sec). ACT was lower than 250 in 12.7% of patients (95% CI: 8.2%-17.2%). ACT had a range of 250-350 seconds in 37% of patients. Overall, 21 patients (10.3%) had ischemic complications (including chest pain, new ischemic changes in EKG, unstable angina and 2 deaths) and 3 patients (1.5%) had bleeding complications. Ischemic complications were significantly higher in smokers (16%) versus nonsmokers (6%, P=0.038) and in patients with ≥2 risk factors (12%) versus those with £1 risk factor (4%, P=0.046). All three patients with bleeding complications were hypertensive (P=0.02). Although this study shows relative safety of conventional heparin dose in PCI, but only about one third of our patients reached desired ACT values (250-350 sec). So it seems appropriate to use weight adjusted heparin doses (e.g. 100u/kg) instead of conventional dose and to assess ACT in all patients and use additional heparin doses to maintain ACT at optimal levels (Iranian Heart Journal 2008; 9 (1): 18-21). Although this study shows relative safety of conventional heparin dose in PCI, but only about one third of our patients reached desired ACT values (250-350 sec). So it seems appropriate to use weight adjusted heparin doses (e.g. 100u/kg) instead of conventional dose and to assess ACT in all patients and use additional heparin doses to maintain ACT at optimal levels (Iranian Heart Journal 2008; 9 (1): 18-21). 29 R. Parvizi MD, S. Negargar MD, B. Nagili MD and S. Hassanzadeh Salmasi, MSc Infective endocarditis is a disease caused by the microbial infection of the endothelium, which covers the inner layer of the heart. Different studies in advanced countries have reported the incidence of the disease from 1.6 to 6 in 100,000 patients. This retrospective analysis was conducted at Shaheed Madani Hospital of Tabriz between 1995 and 1999. The patients who lacked diagnostic symptoms of endocarditis, and those who were diagnosed on the basis of clinical signs were excluded from the study, and 20 patients who had endocarditis of the native valves were studied. The information was collected through a questionnaire including demographic information, blood samplings, pathologic results, reports of echocardiography and radiology, feverish syndromes, records of antibiotic use, and the signs of disease. Information was analyzed using the statistical program of SPSS WIN. Twenty patients at an average age of 34 years with native valve endocarditis were selected for the study. 65% of these patients were male and 35% were female, and 17 patients had complete results of their blood culture test. Staphylococcus aureus was obtained in 11.67% of the cases, and two cases were positive for beta-hemolytic streptococcus (11.72%). In the analysis of cardiac complications, none of the patients had myocardial infarction and angina, 6 cases had embolism, 10% had no arrhythmias, and another 10% had heart block. Three of the patients had neurologic lesions, and radiological findings in 9 cases were abnormal. Eleven patients underwent open-heart surgery. The minimum duration of hospitalization was 6 days and the maximum 94 days. 80% of the patients recovered, while 20% died. Three patients had Brucella endocarditis, which was diagnosed via the Wright test. The most common site of infection was the aortic valve. Rheumatic fever is a universal disease, the outbreak of which is very high in the countries which have poor economic conditions, are overpopulated, and have substandard living conditions. These conditions cause the rapid transmission of rheumatogenic streptococcus. Improving these conditions and proper and timely antimicrobial treatment can decrease the prevalence of rheumatic fever as well as endocarditis (Iranian Heart Journal 2008; 9 (1): 22-28). cardiac patients ■ endocarditis ■ heart valve 30 M. Y. Aarabi Moghadam MD, A. A. Shah Mohammadi MD, S. M. Meraji MD, P.N. Davari MD, G. R. Omrani MD and S. R. Miri MD Atrial septal defect (ASD) operation is a safe and low-risk procedure. Cosmetic results have been an important issue, so right anterolateral thoracotomy (RALT) approach has been used for repair. However, in RALT, the skin incision usually crosses the future breast line, which may cause breast mal-development. We reviewed the long-term results of a consecutive series of 406 patients from 1997- 2005 in whom the ASD was closed through a RALT or median sternotomy (MS) incision. 190 patients were male and 216 were female, with a mean age of 8.2±3.9 years. Defects repaired included 383 ASD secundum (ASD 2º) and 23 ASD sinus venosus type (ASD-SV). In 316 patients (77.8%), the defect was closed through MS, and 90 patients (22.2%) underwent RALT for repair. The mean cardiopulmonary bypass time (CPB time) was 37.0±10 min. for MS vs. 40±11 min. for RALT (p=0.9, NS). Intubation time after operation was 9.0±5 hrs for MS and 8.1 ±7.1 hr in RALT (p=0.8, NS). Postoperative drainage was 119mL (range, 0-1100mL) for MS and 94mL (range, 0-500mL) in RALT (p=0.1, NS). Postoperative pleural/pericardial effusion and pneumothorax occurred in 2.1% of patients in MS and 6.6% in RALT group (p= 0.001). There was no operative or late mortality, morbidity or breast maldevelopment in the long-term follow-up (range, 6 m -10 y, mean 4 yrs). RALT is a safe and effective alternative approach to MS incision for ASD closure (Iranian Heart Journal 2008; 9 (1): 29-33). atrial septal defect ■ right anterolateral thoracotomy ■ cardiac surgery ■ median sternotomy 31 H. Shemirani MD and F. Abbasian* MD Lp (a) lipoprotein has structural homology with plasminogen and has been shown to Serum Lp (a) lipoprotein concentration was measured in 135 consecutive patients admitted with a diagnosis of AMI who received SK treatment. Recovery and non-recovery from myocardial injury was assessed by the reduction in sum of ST segment elevation measured from the J point (STJ) and Q wave formation in electrocardiography immediately before SK was given compared with two hours later. Serum Lp (a) lipoprotein concentration was measured within 6 hours of onset of symptoms and before SK was administrated, and was higher than that in healthy reference populations. Thirty-one patients with high anti-streptokinase antibody levels were excluded. In patients with Q wave AMI and low anti-streptokinase antibody levels, 31 patients (50%) had high level Lp (a) lipoprotein (34.2mg/dl), whereas patients with non-Q wave AMI and reduction in ST segment elevation after SK >50% (median decrease) had a mean serum Lp (a) lipoprotein concentration of 18mg/dl. The difference was not statistically significant. In this study, Lp (a) lipoprotein concentration did not significantly influence the outcome of thrombolytic treatment with SK (Iranian Heart Journal 2008; 9 (1): 34-39). streptokinase ■ lipoprotein ■ myocardial infarction 32 Habibollah Yadollahi Farsani, MD and Akbar Shahmohammadi Beni*, MD Bicuspid aortic valve (BAV) is the most common congenital heart disease and the most common malformation of aortic valve. In BAV, there are two cusps instead of three cusps in the aortic valve. The objectives of this study were the determination of the aortic root dilatation and other anatomic and hemodynamic characteristics and abnormalities of BAV. Thirty patients and 30 control subjects were evaluated. Aortic root dimensions were measured via two-dimensional echocardiography (2-D echo) at 4 levels, including the aortic valve annulus, sinuses of Valsalva, sinotubular junction (STJ) and proximal ascending aorta (AAO). Hemodynamic data and anatomic characteristics were measured using 2D and Doppler-echo. All the findings were matched and indexed for body surface area (BSA) and were compared with the matched data of the control subjects. Clinical and demographic findings of BAV were also determined and collected through a questionnaire. Among the patients, 70% were male and the mean age and weight of the patients were 7.5 years and 22.13 kg, respectively. 86.66% of the patients had systolic ejection murmur (SEM), 76.66% systolic ejection click (SEC) and 10% had chest pain. Other congenital heart diseases (CHD) were found in 26.96% of the patients, including coarctation of the aorta (CoA) in 23% of the cases. Matched mean anatomic aortic valve area (AAVA) was 2.05cm2/m2 , and matched mean effective aortic valve area (EAVA) was 1.41cm2/m2 BSA. Maximum aortic valve pressure gradient (PG max) in systole was 56.56mmHg. Forty percent of the patients had aortic stenosis (AS): mild AS in 16.66%, moderate AS in 13.33% and intermediate AS in 10%. Prevalence of aortic insufficiency (AI) was 36.68%. When the data were compared with the control subjects, all the patients showed a meaningful larger aortic root dimension at all 4 levels (P values are presented in Table IV). Aortic root dilation was at the level of the annulus, sinuses of Valsalva, STJ and proximal AAO in 6.25%, 4.75%, 10.20% and 10.13%, respectively. These findings support the hypothesis that BAV and aortic root dilation may reflect a common developmental defect. AS and AI are common in BAV. Similar to other obstructive defects of the left heart, BAV is significantly more common in males. Because murmurs and clicks are common in BAV even without AS or AI, all patients with a heart murmur and/or click must be evaluated for BAV (Iranian Heart Journal 2008; 9 (1):40 -46). bicuspid aortic valve ■ congenital heart disease ■ aortic root dilation ■ children 33 Hossein Talavat MD, Abdollah Panahipour MD, Gholamali Mollasadeghi MD, Masood Ghorbanloo MD and Farzad Fazeli MD Coronary artery bypass grafting surgery (CABG) is a commonly performed procedure. More than 10,000 CABG surgery procedures are performed in Iran annually. Prolonged mechanical ventilation following CABG surgery is uncommon. Economic factors have led to a trend for early tracheal extubation after CABG. Fast-track extubation is variously defined but most agree that it refers to extubation within 8 hours. A descriptive observational study was conducted on 196 patients undergoing CABG surgery. Following surgery, standard weaning protocol was implemented. Patients who failed to be extubated within 8 hrs were evaluated. Four patients (2.04%) died within 3 to 12 days. After undergoing surgery, the minimum duration of mechanical ventilation was 2 hrs, up to a maximum duration of 19 days. 94.3% of the patients were extubated within 24 hrs, with a mean duration of 9.54 hrs. 5.7% of the patients were still intubated after 24h. The most common cause of delayed extubation was physician trend (n=27, 13.8% of patients). Reduced ejection fraction, EKG changes, elderly age, prolonged CPB, difficult intubation were reasons for this trend. The second most common cause was excessive postoperative bleeding, which occurred in 13.3% of the patients. Four percent of the patients were returned to the operating room for re-exploration. Cardiovascular instability (11.7%), metabolic acidosis (9.7%), prolonged recovery (4.7%), neurologic problems (2%), poor FVC (4.6%), hypoxemia (1.5%), and acute respiratory distress syndrome (ARDS) (0.5%) were other reasons. The incidence of prolonged mechanical ventilation for more than 24h was similar to that of the STS database.8 We found the most common cause of delayed extubation to be physician trend. We recommend changing our strategy in these patients. Excessive postoperative bleeding incidence in our study was slightly higher than that in other studies. We found the proportion of patients with failure to extubate due to various reasons would vary from institution to institution, based on differences in patient population and management strategies(Iranian Heart Journal 2008; 9 (1):47 -54). coronary artery bypass grafting surgery ■ prolonged mechanical ventilation 34 Naser Mozaffari MD,* Alireza Fadaee Naeeni MD** and Shahrokh Attarian MD** Increase in trauma and aging in recent decades has been associated with an increase in orthopedic operations in the limbs and their concomitant iatrogenic vascular complications. Although vascular injuries during orthopedic operations are uncommon, timely diagnosis and treatment is essential. These injuries can occur due to laceration, compression, or traction of the vessels in proximity to bony structures such as vertebrae, hip and knee joints, and long bones. Primary signs are bleeding or ischemia. The best results will be obtained with prompt diagnosis and treatment; otherwise, there is a risk of complications such as pseudoaneurysm or limb loss. The presented case is a 22-year-old male with a history of right tibial fracture following a motorcycle accident one year before, which was treated with internal plate fixation. Following the operation, an enlarging mass developed in the posterior aspect of his leg. Upon evaluation, it was noted that a screw used for internal fixation had injured the posterior tibial artery and led to tibial artery pseudoaneurysm. Surgical treatment was done. Such a complication has not been reported in the literature. In the presence of even minimal ischemia following bone trauma, vascular evaluation and angiography before any orthopedic operation is critical, and it is recommended that management in such cases be performed in centers where reconstructive vascular surgery is available(Iranian Heart Journal 2008; 9 (1):55 -60). 35 Ali Asghar Bolourian, MD Coronary artery fistula is a rare congenital anomaly with an incidence of about 0.2 - 0.6% in different reports. It is defined as a direct communication between the coronary artery and any surrounding cardiac chamber or vascular structure which bypasses the myocardial capillary bed. Three interesting cases of coronary artery fistula are reported. Two of the patients were symptomatic. In one case, all coronary arteries (in addition to duplicated LAD) were fistulized into the right ventricle. Diagnosis was made by echocardiographic study and coronary angiography. Surgical correction is discussed. In one case, angiography six months later showed no fistula. Serial echocardiography during follow-up was unremarkable (Iranian Heart Journal 2008; 9 (1):64 -68). 143 Majid Maleki MD, Anita Sadeghpour MD, Alireza Moarref MD, Feridoun Noohi MD, Ali Sadeghpour Tabaee MD, Mahshid Ojaghi MD, Maryam Esmailzadeh MD, Niloofar Samiei MD, Ahmad Mohebbi MD and Goldis Malek PhD Cor triatriatum is an unusual congenital anomaly that is probably not as rare as previous reports have indicated. Herein we describe a case of left atrium membrane with multiple large atrial septal defects mimicking cor triatriatum in the absence of pulmonary venous obstruction. We hypothesized that left atrium membrane, when associated with other cardiac lesions, masked pulmonary venous obstruction and that failure to recognize this structure might result in pulmonary venous obstruction at the time of surgical repair of the primary defect and consequently poor surgical outcome (Iranian Heart Journal 2008; 9 (1):61 -63). cor triatriatum ■ left atrial membrane ■ atrial septal defect