4 Payiz 1387 Fall 2008 9 3 10 H. Basiri MD, Z. Khajali MD and S. Abdi MD To investigate the short-term results of percutaneous coronary intervention (PCI) on native coronary vessels in patients with prior coronary artery bypass grafting (CABG). Coronary angiography was performed for 82 patients with prior CABG who presented with typical chest pain during the interval from March 2007 to May 2008. PCI and stenting was performed on the eligible native vessels. The resolution of symptoms and the frequency of hospitalization were evaluated during the 6-month follow-up period. The technical success rate for PCI was 94%; the reduction in hospitalization rate and typical chest pain occurrence and improvement in functional class after PCI were statistically meaningful. There was no statistically significant relation between age, sex, triglyceride level, cholesterol level, diabetes, smoking, and ejection fraction with the above parameters. PCI on native vessels is a well tolerated procedure with a minor morbidity and mortality rate and good symptomatic and anatomical outcome for patients with prior CABG (Iranian Heart Journal 2008; 9 (3):6 -9). coronary artery bypass grafting ■ percutaneous coronary intervention ■ coronary artery diseas 11 Ramin Baghaei MD, Nader Givtaj MD, Mehdi Haddadzadeh MD, Avissa Tabib MD,* Gholamali Mollasadeghi MD,** Ali Sadeghpour MD, and Manouchehr Arjmand MD The true incidence of congenital cardiovascular malformations is difficult to determine accurately, partly because of difficulties in definition. About 0.8 percent of live births are complicated by a cardiovascular malformation. Hypoxia and cyanosis, the common complications of all cyanotic disease, may be life-threatening in severe forms. Today, the trend is towards the total surgical correction of these anomalies in early life. As the accomplishment of this strategy in various parts of the world is not possible, palliative procedures like systemic-pulmonary shunt have retained their importance. Data were collected from the files of 180 patients, for whom systemic-pulmonary shunt was performed by a single surgical group at our center between March 1992 and May 2006. Our aim was to determine the outcome of shunt operation in terms of success rate, morbidity, and mortality. The median age and weight of the patients was 24 months and 10.5 kilograms, respectively. There was a spectrum of underlying cyanotic heart diseases. The main operation was the modified Blalock-Taussig shunt (90%). The mean value of oxygen saturation was 62% pre-operatively, which rose to 85% after surgery. We found a 77.9% success rate, 6.7% mortality rate, and 8.7% morbidity rate. There was no significant correlation between the predictive factors and success of operation. Lower age and weight of the patient, small size of the pulmonary artery, and urgency of operation predicted the operative mortality (Iranian Heart Journal 2008; 9 (3):10 -17). cyanosis ■ systemic-pulmonary shunt ■ central shunt ■ tetralogy of Fallot 12 M. Dehghani* MD, H. Falsolaiman ** MD and Z. Mahmoodi, *** MD The aim of this study was to identify the incidence, angiographic and procedural predictors, and clinical outcome of acute side branch occlusion (SBO) following coronary stent implantation. In total, 138 patients who underwent coronary artery stenting were included. The stents had covered 185 side branches with a luminal diameter greater than 1 mm and less than 2 mm. All the procedures were performed according to the current standards. The data on the clinical events and angiographic characteristics were analyzed. The side branch size and the ostium involvement and its location within the stent were evaluated. SBO was defined as a (thrombolysis in myocardial infarction) TIMI flow ≤1. Acute SBO after stent implantation occurred in 24 (12.9%) side branches. A significant side branch ostial stenosis (≥50%) and side branch diameter at base line ≤1.5 mm were predictors of SBO. Non Q-wave myocardial infarction (MI) was observed in 16.6% of the patients with acute SBO and in 4% of the cases without SBO (P=0.001). However, during hospital stay and long-term follow-up, the incidence of major adverse cardiac events (MACE) comprising death, need for target vessel revascularization, and Q-wave MI was almost similar in the patients with and in those without acute SBO. No MACE related to SBO was seen in these patients. The incidence of acute SBO after coronary stent implantation is relatively frequent. Major predictors of SBO are side branch diameter <1.5 mm and the presence of an ostial side branch stenosis (≥50%). These data yield support to the assumption that the occlusion of small and medium-sized branches during coronary artery stent implantation is not associated with an adverse clinical outcome and should not hinder an optimal interventional therapy of the target lesion (Iranian Heart Journal 2008; 9 (3):18 -24). coronary artery disease ■ side branch occlusion ■ stent implantation 13 Majid Maleki1 MD, Sepideh Pezeshki2 MD, Seyyed Mohammad Fereshtehnejad MD The clinical syndrome of heart failure (HF) remains a leading cause of cardiac morbidity and mortality. The coming years will see a continuous growth in the epidemic of HF and increasingly complex pharmacological, interventional, and device-based therapies, effective in reducing HF morbidity and mortality. Highly trained clinician-specialists are needed to assist in optimally evaluating and managing patients with HF. The aim of the present study was to determine the best management protocol for HF by surveying different therapeutic protocols (medical, cardiac resynchronization therapy [CRT] program, and enhanced external counterpulsation [EECP]). Initial assessment was performed for a total of 280 HF patients evaluated in the Heart Failure Clinic. Eighty patients were included in the study; the selection being done in accordance with the inclusion criteria of ejection fraction (EF) £35%. By surveying different therapeutic protocols, disease management programs (DPMs), namely medical, CRT, and EECP, were performed in three study groups: group A; medical therapy (n=37), group B; EECP (n=16), and group C; CRT (n=27). Changes in New York Heart Association (NYHA) functional class and echocardiographic indexes were evaluated in the three groups. There was no significant change in EF, left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and E/E' ratio after medical therapy. There was, however, a significant improvement in NYHA function class (P <0.001). EECP significantly improved EF (P<0.05) and E/E' ratio (P<0.001). There was also a significant reduction in LVESV (P<0.05) with improvement in NYHA functional class and rehospitalization (P<0.001). CRT significantly reduced LVESV, LVEDV (P<0.05), E/E' ratio (P<0.001), and EF (P<0.001).There was improvement in NYHA functional class and rehospitalization as well (P<0.001). Our findings suggest that disease management programs or guideline-based treatments reduce first hospitalization and rehospitalization rates in patients with heart failure and improve NYHA functional class and the echocardiographic findings of LVESV, LVEDV, LVEF, and E/E' ratio. In the hope of improving HF outcomes, disease management programs (medical care, EFCP, CRT-D implantation, etc.) have been developed to standardize and optimize HF treatment, focusing on disease education for the patient and continuing support after hospital discharge (Iranian Heart Journal 2008; 9 (3):25 -36). heart failure (HF) ■ disease management programs ■ enhanced external counterpulsation ■ cardiac 14 Ahmad Mohebbi MD, Mehrdad Honarvar MD, and Ashkan Behzadi MD The anticoagulation activity of warfarin is monitored by the prothrombin time (PT) using the international normalization ratio (INR). Factors such as genetic polymorphism and ethnic differences can cause an unpredictable dose response. In our study, the primary end point was time in days to therapeutic INR in the Iranian race. The secondary end point was time in days to stable dose for our patients, and the third end point was determination of stable dose related to sex and age distribution of our patients. The anticoagulation clinic records of patients taking warfarin during an index period were retrospectively reviewed. INR measurements were performed on citrated venous blood samples. Under-anticoagulation was defined as any out of range INR<1.8 and overanticoagulation as INR >3.4. Stable warfarin dose was achieved in only 5% of the patients by day 14, 55% by day 21, 85% by day 28, and >95% by day 35. The mean stable dose showed an inverse relation with the day 5 INR. However, about 12% of the patients required a final stable dose of < 2.5 mg. No patients suffered any hemorrhagic or thrombosis episodes during the first month of warfarin therapy. After the first month, hemorrhagic complications such as gum bleeding, hematuria, and bloody stool were seen in about 5.5%; however, hospitalization due to hemorrhagic cardiovascular accident was less than 0.7% and thrombosis events were less than 2%. We conclude that warfarin dose during the second and third weeks was highly predictive of the patients’ "stable dose", which is different from the time to reach the therapeutic INR level (Iranian Heart Journal 2008; 9 (3):37- 41). warfarin ■ stable dose ■ therapeutic dose ■ international normalization ratio ■ prothrombin time 15 M. Dehghani* MD, H. Falsolaiman ** MD and Z. Mahmoodi, *** MD The aim of this study was to identify the incidence, angiographic and procedural predictors, and clinical outcome of acute side branch occlusion (SBO) following coronary stent implantation. In total, 138 patients who underwent coronary artery stenting were included. The stents had covered 185 side branches with a luminal diameter greater than 1 mm and less than 2 mm. All the procedures were performed according to the current standards. The data on the clinical events and angiographic characteristics were analyzed. The side branch size and the ostium involvement and its location within the stent were evaluated. SBO was defined as a (thrombolysis in myocardial infarction) TIMI flow ≤1. Acute SBO after stent implantation occurred in 24 (12.9%) side branches. A significant side branch ostial stenosis (≥50%) and side branch diameter at base line ≤1.5 mm were predictors of SBO. Non Q-wave myocardial infarction (MI) was observed in 16.6% of the patients with acute SBO and in 4% of the cases without SBO (P=0.001). However, during hospital stay and long-term follow-up, the incidence of major adverse cardiac events (MACE) comprising death, need for target vessel revascularization, and Q-wave MI was almost similar in the patients with and in those without acute SBO. No MACE related to SBO was seen in these patients. The incidence of acute SBO after coronary stent implantation is relatively frequent. Major predictors of SBO are side branch diameter <1.5 mm and the presence of an ostial side branch stenosis (≥50%). These data yield support to the assumption that the occlusion of small and medium-sized branches during coronary artery stent implantation is not associated with an adverse clinical outcome and should not hinder an optimal interventional therapy of the target lesion (Iranian Heart Journal 2008; 9 (3):18 -24). coronary artery disease ■ side branch occlusion ■ stent implantation 16 M. H. Nezafati MD, M. Abbasi MD, G. Soltani MD and N. Zirak MD Early post-operative arrhythmias are a known complication of cardiac surgery; however, there is a paucity of data specific to pediatric heart surgery. The purpose of this study was to evaluate the occurrence rate and type of early post-operative arrhythmias in children. Data were collected in a prospective observation of pediatric patients undergoing cardiac surgery between December 2001 and December 2005. All consecutive patients undergoing well-defined surgical procedures were prospectively evaluated for the occurrence rate and type of early postoperative arrhythmias that occurred in the ICU and during the post-operative hospital stay by means of continuous electrocardiographic monitoring in the intensive care unit and use of 24-hour Holter monitors. All the operations were performed by one surgeon throughout the study period. The procedures were performed with cardiopulmonary bypass (CPB) and moderate hypothermia (28-32º C) using anterograde crystalloid cardioplegia for myocardial protection. To determine the relationship between the age of the patients and the degree of post-operative arrhythmia, the patients were divided into 17 age groups. Arrhythmias occurred in 231 of the 658 patients (35.01%). The most common types of arrhythmia were junctional rhythm (47), premature atrial contractions (PACs) (40), bradycardia (39), and premature ventricular contractions (PVCs) (28). The total correction operations for the tetralogy of Fallot (TOF), atrial septal defect (ASD) repair, and ventricular septal defect (VSD) repair were the procedures in which the most post-operative arrhythmias occurred. The occurrence rate of arrhythmias was higher in the infants (202-57 arrhythmia 30.69%) and in TOF (205-102 arrhythmia 46%). Postoperative atrioventricular (AV) block was observed in 18 (7%) patients, 10 of whom had a complete AV block (4%), comprising 4 VSD repairs, 4 TOF repairs, and 2 complete AV canal repairs, and 5 and 3 had second- and first- degree AV blocks, respectively. During the whole study period, 48 (21%) patients died because of a post-operative arrhythmia. The total number of deaths was 97 (15%). Approximately 1/3 of all the patients experienced cardiac arrhythmia during the early postoperative period after open heart surgery for congenital heart disease, and a higher occurrence rate of arrhythmias was found in the infants and cyanotic children. Junctional arrhythmia, PACs, bradycardia, and PVCs were the most frequent arrhythmias (Iranian Heart Journal 2008; 9 (3):53 -58). congenital heart disease ■ junctional tachycardia ■ post-operative arrhythmia ■ cardiac surgery 17 Zeinab Amirimoghaddam MD,* Maliheh Khoddami MD,** Seyed Farzad Azarin MD,*** Sahar Sadr MD,**** and Amir Parvazian MD Although the involvement of the heart by malignancy is relatively common, it is unusual for it to be detected premortem. In addition, there is a dearth of data on this subject in the literature. We report a case of Hodgkin’s lymphoma presenting with systemic signs and symptoms including abdominal distension, weakness, pallor, chills and fever, generalized edema, hepatosplenomegaly, and generalized lymphadenopathy, as well as signs of heart failure. Echocardiography revealed pericardial effusion, left ventricular hypertrophy, and lucent myocardial lesions. Right cervical lymph node biopsy established the diagnosis of nodular sclerosing type Hodgkin’s lymphoma with the involvement of the bone marrow at biopsy. After 14 sessions of chemotherapy, systemic and cardiac abnormalities improved. We believe this is the first case of Hodgkin’s lymphoma with cardiac metastasis and heart failure (Iranian Heart Journal 2008; 9 (3):59 -61). Hodgkin’s lymphoma ■ heart failure ■ cardiac metastasis 18 M. Hasan Kalantar Motamedi MD,* Ali Hemmat MD, † and Pooya Kalani MD. †† True aneurysms of the renal arteries are a very rare entity. Herein we describe a case of saccular left renal artery aneurysm found as an incidental angiographic finding in an adult, hypertensive female. She also had an accessory renal artery supplying the lower third of the left kidney. She underwent surgery, during which the large renal artery aneurysm was resected and the renal blood flow restored with aortorenal bypass graft with autologous saphenous vein. Postoperative recovery was uneventful, and her blood pressure is presently well- controlled (Iranian Heart Journal 2008; 9 (3):69 -72).