5 Tabestan 1387 Summer 2008 9 2 19 Saeid Hosseini MD, Mehdi Hadadzadeh MD, Mohammad Baqer Tabatabaee MS, and Alireza Alizadeh Ghavidel MD The present study was conducted to report our clinical experience with aortic arch replacement using selective cerebral perfusion (SCP) to evaluate the safety and usefulness of this technique. From October 2003 to April 2007, 10 patients (mean age 51.2 years) underwent arch replacement for acute type A dissection involving the aortic arch. Operations were performed with hypothermic cardiopulmonary bypass using antegrade selective cerebral perfusion during the arch surgery. Seven patients (70%) have a history of hypertension. Six patients (60%) underwent total arch replacement and the other four (40%) had semiarch replacement. Associated coronary artery bypass graft surgery (CABG) was performed in 2 patients (20%). The mean follow-up period was 10.39 months (ranging from 1 to 42 months). Mean aortic cross-clamp time, CPB time and partial circulatory arrest time with antegrade cerebral perfusion were 121.4 (95-165), 257.7 (230-290) and 16.5 (13-22) minutes, respectively. There were two hospital mortalities and one cerebral complication. All inhospital mortalities were in our five first cases, indicating perhaps a learning curve for this operation. During the follow-up period, no patient underwent reoperation because of recurrence of dissection. All surviving patients are still alive and free from any serious events at the time of this writing. Selective cerebral perfusion is a reliable technique for cerebral protection and it facilitates the complex and time-consuming total arch replacement (Iranian Heart Journal 2008; 9 (2):6-9). aortic arch surgery ■ selective cerebral perfusion 20 Hossein Ali Bassiri MD, Khadijeh Ghanbarian MD and Majid Haghjoo MD* Atrial fibrillation (AF) is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care. Suitable treatment and prevention of postoperative AF are important for patients’ improved health and rehabilitation. This study evaluates the risk factors of paroxysmal AF in patients who underwent valvular heart surgery. Between April and October 2006, 392 patients who underwent heart valve surgery at our center were included in this prospective study. All relevant clinical, echocardiographic, and laboratory data were gathered in all the patients. Postoperative AF occurred in 52 (13.3%) patients. In the univariate analysis, the presence of aortic valve disease, mitral valve disease, dyslipidemia, preoperative digoxin consumption, postoperative adrenergic use, intra-aortic balloon pump (IABP) insertion in post-surgery intensive care unit, and large left atrium were significantly associated with the occurrence of postoperative AF (all P<0.05). However, in the stepwise logistic regression model, dyslipidemia (OR: 2.39, 95% CI: 1.12-5.09, P=0.020), left atrium dimension (OR: 0.12, 95% CI: 0.76-0.28, P<0.001), IABP (OR: 7.10, 95% CI: 1.98-25.47, P=0.001), preoperative digoxin use (OR: 2.55, 95% CI: 1.38-4.71, P=0.002), postoperative adrenergic use (OR:3.70, 95% CI: 1.77-7.73, P<0.001), aortic valve replacement (OR:0.38, 95% CI: 0.20-0.69, P=0.0001), and mitral valve replacement (OR:3.53, 95% CI: 1.75-7.10, P<0.001) remained independently predictive of postoperative AF. The result of this study showed that dyslipidemia, left atrium dimension, mitral valve replacement, aortic valve replacement, IABP, and adrenergic use in ICU and digoxin use preoperatively were the independent predictors of AF after valvular surgery. Therefore, clinical data and echocardiography may be useful in preoperative risk stratification of high-risk patients for the occurrence of postoperative AF(Iranian Heart Journal 2008; 9 (2):10-17). atrial fibrillation ■ postoperative arrhythmia ■ heart valve surger 21 Mohammad Hassan Ghaffarinejad MD, Amir Farjam Fazelifar MD,* Shahram Mohajer Shirvani MD,* Esmaeel Asdaghpoor MD, Farzad Fazeli MD and Freidoun Noohi MD* Continuation or discontinuation of aspirin use in the preoperative period for patients scheduled for elective cardiac surgery has continued to be controversial. In this study, we tried to evaluate clinical outcomes (mortality, postoperative bleeding and perioperative myocardial infarction) in patients who underwent first elective coronary artery bypass grafting and received aspirin during the preoperative period. The study was a prospective, randomized and single-blinded clinical trial. Two-hundred patients were included in the study and divided into two groups. One group received aspirin 80-160 mg and in the other group, aspirin was stopped at least for seven days before operation. The primary end points of the study were in-hospital mortality rate and hemorrhage-related complications (postoperative blood loss in the intensive care unit, reexploration for bleeding and red blood cell and non-red blood cell transfusion requirements). The secondary end point was perioperative myocardial infarction. There were no differences in patients’ characteristics among aspirin users and non-aspirin users. We found a significant difference between postoperative blood loss (608±359.7 ml vs. 483±251.5 ml; P=0.005) and red blood cell product requirements (1.32±0.97 units packed cells vs. 0.94±1.02 units packed cells; P=0.008) in the two groups. There was no significant difference between the two groups regarding platelet requirements and the rate of in-hospital mortality and reexploration for bleeding. Similarly, we found no significant difference in the incidence of definite and probable perioperative myocardial infarction (P=0.24 and P=0.56, respectively) and in-hospital mortality between the two groups. Preoperative aspirin administration increased postoperative bleeding and red blood cell requirements with no effect on mortality, reexploration rate and perioperative myocardial infarction (Iranian Heart Journal 2008; 9 (2):18-22). aspirin ■ postoperative bleeding ■ perioperative myocardial infarction 22 M. Ebrahimi, M. Dargahy and S. Bajouri The anomalous origin of the left anterior descending (LAD) coronary artery from the right coronary artery (RCA) is a rare congenital anomaly. Herein we report an adult male referred to our hospital for an evaluation of his chest pain. Echocardiography revealed hypertrophic cardiomyopathy. Coronary angiography revealed an anomalous origin of the LAD from the RCA. Such an association constitutes an extremely rare congenital condition (Iranian Heart Journal 2008; 9 (2):59-61). anomalous coronary artery ■ hypertrophic cardiomyopathy 23 Farzad Jalali MD,a Seyyed Mohammad Miri MDb and Pegah Karimi Elizei c Prolongation of ventricular depolarization time (QRS duration), particularly in left bundle branch block (LBBB), is commonly associated with many cardiac diseases. We propose 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 conducted in the cardiac ward, CCU and out-patient clinic of our department in Babol from 2000 to 2003, 150 patients with a diagnosis of LBBB were divided into two groups (QRS ≥160 and QRS<160 milliseconds). Then the relationship 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 stepwise method. There was no significant difference in age and sex among the patients with or without LAD and QRS duration less or greater than 160 milliseconds (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±10.545%) of the patients with a QRS duration of ≥160 milliseconds (n=19) was significantly more than the mean±SD EF (23.89±5.466%) 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 value. The QRS duration has a significant inverse relationship with EF and 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 2008; 9 (2):29-36). QRS duration ■ electrical axis ■ LV dysfunction ■ ejection fraction ■ left bundle branch block 24 Afsaneh Forood MD* and Mohammad Masomi MD Silent myocardial ischemia is more common in diabetic patients than others. Early detection plays an important role in the prevention of acute myocardial infarction and sudden cardiac death. Routine screening of all diabetics is costly. The aim of this study was to estimate the prevalence of silent myocardial ischemia in type 2 diabetes and define these highrisk patients by routine screening tests. Between May 2004 and May 2006, this cross-sectional study was performed on 500 type 2 diabetic patients referred to Kerman internal medicine and cardiovascular clinics. Inclusion criteria were age between 35 and 70 years, absence of symptoms and resting electrocardiographic signs of ischemia, evidence of retinopathy or peripheral vascular disease, or at least one major atherogenic risk factor (except diabetes). All the patients underwent treadmill exercise test or thallium scintigraphy with exercise or dipyridamole injection. Data were analyzed with chi-square, t-test, and Mann-Whitney U tests. Five hundred patients, comprised of 232 men and 268 women, were evaluated. Screening tests were positive in 86 (17.2%) patients. There was a significant statistical relation between the duration of diabetes, low density lipoprotein cholesterol, family history of coronary artery disease (CAD), retinopathy, and peripheral vascular disease with silent myocardial ischemia (P<0.05). The prevalence of silent ischemia was not significantly different between the males and females (P>0.05). Among the patients with silent ischemia, body mass index was higher in the females and cigarette smoking was more common in the males (P<0.05). With regard to the high frequency of silent myocardial ischemia in type 2 diabetes mellitus, routine silent ischemia screening by exercise stress test should be recommended in type 2 diabetes if any of these conditions are present: duration of diabetes more than ten years, family history of CAD, LDL cholesterol higher than 160 mg/dL, retinopathy, or peripheral vascular disease (Iranian Heart Journal 2008; 9 (2):37-42). type 2 diabetes ■ silent myocardial ischemia ■ coronary artery disease 25 M. Mokhtari-Dizaji PhD, P. Abdolmaleki2 PhD, H. Saberi3 MD, and T. Rahmani1 MSc Early detection of stenosis in carotid artery is essential because it directly affects the patients' clinical management and is of prognostic value. Therefore, estimating mechanical properties of this artery in normal and atherosclerosis cases is important as far as medical treatment is concerned. We applied a logistic regression model to predict carotid artery stenosis in a group of patients based on the quantitative features extracted from the processing of the conventional color Doppler ultrasound images. Our database includes 128 patient records consisting 10 quantitative features. The database is then randomly divided into the training and validation samples including 98 and 30 patient records respectively. The training and validation samples are used to construct the logistic regression model and to validate its performance. Finally, important criteria such as sensitivity, specificity, accuracy and receiver operating characteristic curve (ROC) analysis for this method are evaluated. Our results show that the logistic regression model is able to classify correctly 28 out of 30 cases presented in the validation sample. The output of this method showed a high positive predictive value of 94%. We have established a logistic discriminator approach which is able to predict the probability of stenosis in the carotid artery using features extracted from ultrasonic measurements on ultrasound imaging (Iranian Heart Journal 2008; 9 (2):43-50). color Doppler ultrasound ■ carotid artery stenosis ■ mechanical properties ■ logistic regression analysis 144 Ali Sadeghpour Tabaee MD*, Shahryar Mali MD**, Jalal Vahedian MD*** and Soheila Arefi MD**** Ascending aortic aneurysm is a relatively rare complication of Takayasu’s arteritis. We report a 54 year old lady, a known case of Takayasu’s syndrome, who was operated for the second time because of aneurysmal change in the ascending aorta (Iranian Heart Journal 2008; 9 (2):55-58). aortic aneurysm ■ Takayasu’s syndrome ■ aortitis ■ pulselessness 145 Fatemeh Haji Ebrahim Tehrani MD, Hadi Kazemi MD, Saied Mojtahedzadeh MD and Jahan Oudj MD Patent ductus arteriosus is found in 45% of infants under 1500gr and in infants weighing < 1000gr, the incidence is closer to 80%. Indomethacin has been shown to close the ductus arteriosus in a large fraction of premature infants. Intravenous ibuprofen was recently shown to be as effective and to have fewer adverse reactions in preterm infants. If equally effective, then oral ibuprofen for patent ductus arteriosus (PDA) closure would have several important advantages over the intravenous route. This study was designed to determine whether oral ibuprofen treatment is efficacious and safe in closure of PDA in very low birth weight infants with respiratory distress syndrome (RDS). 30 preterm newborns (gestational age 28.3±2.6 weeks), mean weight 1130±312gm, with PDA and RDS were studied prospectively. They received oral ibuprofen suspension 10mg/kg/body weight for the first dose, followed at 24 hour intervals by two additional doses of 5mg/kg each, if needed, starting on the second day of life. Echocardiographies were performed before treatment and 24 hours after the second dose. The rate of ductal closure, the need for additional treatment, side effects, complications and the infants’ clinical courses were recorded. Ductal closure was achieved in 28 newborns (93.3%), and in two others partial closure was achieved with no important shunts persisting. No infants required surgical ligation of ducts. There was no reopening of the ductus after closure had been achieved. 21 newborns were treated with one dose of ibuprofen, five were treated with two doses and the remaining two were treated with three doses. There were no significant differences in the levels of serum creatinine before and after treatment with oral ibuprofen. Oral ibuprofen suspension may be an effective and safe alternative for PDA closure in premature infants with PDA. However larger comparative studies are warranted (Iranian Heart Journal 2008; 9 (2):23-28). ibuprofen ■ very low birth weight ■ patent ductus arteriosus