en 2008-2290 gregorian 2009 8 1 jalali 2 4 print 8 fulltext

Case Report Pulmonary emboli,Respiratory failure,Thromboendarterectomy 38 40 http://www.iscs.org.ir/journals/vol.2/no.4/56/

Case Report Abstract: A 30-year-old woman presented with doxorubicin-induced heart failure. She had been treated due to Ewing’s sarcoma five years ago. Traditional heart failure treatment has been performed but its effect was mostly very limits. We, therefore, decided to perform heart transplantation for her. doxorubicin-induced heart failure, Heart transplantation, Ewing’s sarcoma 35 37 http://www.iscs.org.ir/journals/vol.2/no.4/55/

Original Article Background: The benefit of cerebrospinal fluid (CSF) drainage during thoracic aortic repair has been established. Few studies, however, report management and safety of CSF drainage. Methods: Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed, with 82% using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia. Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All drains were inserted by cardiovascular anesthesia staff. Repairs were performed using distal aortic perfusion with heparinization. Early management involved free drainage to maintain CSF pressure less than10 mm Hg, but was later modified to limit CSF drainage unless neurologic deficit occurred. Results: Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal headache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2). Spinal headaches resolved with conservative management. All CSF leaks resolved, but 71% (5/7) required blood patches. Since implementation of a limited CSF drainage protocol, no subdural hematomas have been observed. Conclusions: Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Standardizing CSF management may be beneficial. Brain Protection,CSF,Aortic surgery,Aortic Aneurgsm 34 0 http://www.iscs.org.ir/journals/vol.2/no.4/54/

Original Article Objective: The ideal valve substitute in children does not exist. Biologic and bioprosthetic valves do not require anticoagulation, however their use is complicated by accelerated degeneration and requirement for reoperation. We examine results following mitral (MVR) or aortic (AVR) replacement with biologic and bioprosthetic valves at our institution. Methods: Medical records of children who underwent AVR or MVR from 1986 to 2006 were reviewed. Median follow-up duration was 10.5 years. Competing-risks methodology determined time-related prevalence and associated factors for three mutually exclusive end states: death, valve reoperation, and survival without subsequent reoperation. Results: One hundred and ten children (age 15.6 ± 2.6 years, 80% females) underwent 123 valve replacements with biologic and bioprosthetic substitutes including 87 MVR and 36 AVR (13 had both). Underlying pathology was mainly rheumatic fever (91%). Thirty-nine patients (35%) had undergone a previous cardiac surgery. Most common mitral substitute was Hancock (73%) and homograft (8%); most common aortic substitute was homograft (41%) and Carpentier–Edwards (39%). Competing-risks analysis showed that 15 years after valve replacement, 16% of patients had died without subsequent reoperation, 66% underwent valve reoperations, and only 18% remained alive without further reoperation. Factors associated with increased reoperation risk included younger age at surgery (p = 0.005), AVR (p = 0.005), male gender (p = 0.02) and homograft use (p = 0.007) especially in the mitral position (p = 0.002). Fifteen-year freedom from endocarditis was 97% while freedom from bleeding and thrombo-embolic complications was 100%. Majority of patients (95%) were in NYHA functional classes I/II at last follow-up. Conclusion: While valve reoperation is inevitable following AVR and MVR with biologic and bioprosthetic substitutes; favorable results such as low valve-related morbidity rate, good long-term survival and functional status encourage their consideration as valid replacement alternatives in selected children especially females. Valve durability is higher in the mitral position and longevity of bioprosthetic valves is greater than that of homografts especially in the mitral position. Mitral valve replacement • Aortic valvereplacement • Rheumatic fever • Homograft • Pulmonary autograft • Bioprosthetic valve 33 34 http://www.iscs.org.ir/journals/vol.2/no.4/53/

Original Article Objective: Chronic volume overload in repair of tetralogy of Fallot (TOF) with transannular patch leads to significant late morbidity and mortality. Preserving pulmonary valve integrity offers a better long-term prognosis, despite a risk of residual stenosis. In our study we analyzed the evolution of pressure gradients in patients operated with conservative approaches, with particular regard to those babies with an immediate postoperative Prv/Plv ratio 0.70. Methods: Between January 2000 and June 2008, 24 patients with TOF underwent reparative surgery with a valve sparing procedure (median age 8.1 months, range 1.1–86.6). The intraoperative post-repair echocardiography showed a Prv/Plv ratio 0.70 in eight patients (33%, group A) and <0.70 in 16 patients (67%, group B). We realized a retrospective study of pre-, intra-, and postoperative data and of clinical and echocardiographic follow-up data. Results: There was no early or late mortality, nor functional or rhythmic disturbances. One patient required re-operation for residual stenosis at annular level at one year. After a median follow-up of 32.8 months (range 0.6–73.1), the Prv/Plv ratio decreased by 16% (p = 0.001) in all patients. In group A the reduction was 28% (p = 0.018) and in group B it was 12% (p = 0.14). Conclusions: After a valve sparing procedure there is a reduction of Prv/Plv ratio at medium-term follow-up; in our study this reduction was statistically significant in all patients and in the subgroup with higher postoperative ratios. A valve sparing strategy reduces pulmonary regurgitation, preserves RV function and decreases the incidence of late arrhythmias, which are the determinants of long-term outcome. Tetralogy of Fallot • Pulmonary valve sparing • Cardiac congenital 33 0 http://www.iscs.org.ir/journals/vol.2/no.4/52/

Original Article Background: Excellent surgical results have been reported after repair of complete atrioventricular septal defects (CAVSD); however, 5% to 10% require reoperation. We examine causes leading to reoperation and evaluate long-term outcome. Methods: Between 1972 and 2007, 50 patients (26 male) underwent reoperation at our institution after initial repair of CAVSD (median interval, 15 months; range, 3 days to 29 years). Median age at first reoperation was 4.5 years (range, 53 days to 38 years). Indications for first reoperation included left atrioventricular valve (LAVV) regurgitation in 41 patients, subaortic stenosis in 5, and LAVV stenosis, residual atrial septal defect (ASD), pulmonary artery (PA) stenosis, and aortic coarctation in 1 each. Results: The first reoperation included LAVV repair in 21 patients and replacement in 21, modified Konno procedure in 3, septal myectomy in 2, and PA reconstruction, coarctation repair, and ASD re-repair in 1 each. After LAVV repair (n = 21) 5 patients required a second reoperation, and after LAVV replacement (n = 21) 6 patients required a second reoperation. Overall freedom from further reoperation after the first reoperation was 63%, 48%, and 42% at 5, 10, and 15 years, respectively. There were 2 early deaths (4%) after first reoperation, and none after subsequent reoperations. During late follow-up (median 10.7 years, maximum 30 years), actuarial overall survival was 91%, 91%, and 86% at 5, 10, and 15 years, respectively. Conclusions: The most common indication for reoperation after CAVSD repair is LAVV regurgitation. LAVV re-repair offers good durability, and LAVV replacement does not preclude additional reoperations. Long-term survival is very good despite need for multiple reoperations in some. Congenital heart disease,Re-operation,AV Septal Defect 32 33 http://www.iscs.org.ir/journals/vol.2/no.4/51/

Original Article Objective: For most newborns, congenital heart defects (CHD) appear to be isolated anomalies and the brain is presumed to have normal developmental potential. Most studies of neurodevelopmental outcomes have focused on operative management strategies. Methods: Infants with complex CHD and no identified syndromes other than 22q11 microdeletions enrolled in a study of apolipoprotein E (APOE) polymorphisms and developmental outcome were evaluated at one year of age; including genetic evaluation and the Bayley Scales of Infant Development-II [mental (MDI) and psychomotor developmental indices (PDI)]. Results: Five hundred and fifty infants enrolled and 359 (20 with 22q11) of 501 survivors (72%) returned. Mean MDI was 90 ± 15 and PDI was 78 ± 18. Genetic syndromes not identified at birth were confirmed in 28 (8.1%) and suspected in 51 (15.0%). By multivariable analysis, suspected/confirmed genetic syndromes and APOE 2 allele predicted lower MDI and PDI, all p < 0.04. Lower birth weight (p < 0.001) and preoperative intubation (p = 0.012) predicted lower MDI. Higher hematocrit during the initial operation was associated with higher MDI (p = 0.007). Longer postoperative length of stay was predictive of lower PDI (p = 0.002). Additional operations with cardiopulmonary bypass were associated with lower MDI and PDI (both p < 0.002), but use of deep hypothermic circulatory arrest was not. Conclusions: Patient factors (birth weight and preoperative status) are significant determinants of neurodevelopmental outcomes as opposed to operative management strategies. In this cohort, genetic syndromes unsuspected at birth were surprisingly common and correlate with poor neurodevelopmental outcomes. Without multiple congenital anomalies, syndromes may be missed in infancy. Genetic evaluation should be considered in all infants with CHD. Abbreviations: APOE = apolipoprotein E • BCAS = Boston Circulatory Arrest Study • CHD = congenital heart defect • CPB = cardiopulmonary bypass • DHCA = deep hypothermic circulatory arrest • MDI = mental developmental index • PDI = psychomotor developmental index • TGA = transposition of the great arteries • TOF = tetralogy of Fallot • VSD = ventricular septal defect Heart defects • Congenital • Genetic predisposition to disease • Apolipoprotein E Neurodevelopmental outcomes 32 0 http://www.iscs.org.ir/journals/vol.2/no.4/50/

Original Article Objective: Based on the adverse relationship between left ventricular (LV) remodeling and clinical outcome in ischemic cardiomyopathy, surgical ventricular restoration (SVR) is proposed as a valuable adjunct procedure. This study reports on the short-term clinical and hemodynamical performance of SVR. Methods: Using end-systolic LV volume as indication for SVR, 78 patients with ischemic cardiomyopathy are divided in two groups: group 1 comprised 55 patients treated by coronary revascularization and mitral annuloplasty, group 2 comprised 23 patients undergoing additional SVR. Hemodynamic investigation included echocardiographic assessment of systolic and diastolic function. Clinical follow-up focused on survival and functional status with exercise performance. Results: Both surgical approaches resulted in improvement of NYHA class (2.9–1.6 in group 1; 3.3– 1.5 in group 2, p < 0.001), achieving similar exercise performance (peak VO2 13.7 vs 15.4 ml/kg min in groups 1 and 2, p = 0.25) and plasma BNP values (group 1: 1350 pg/ml and group 2: 767 pg/ml, p = 0.23). SVR provided additional benefit as patients basically had a worse NYHA class (2.9 in group 1 vs 3.3 in group 2, p = 0.03). Within mean follow-up of 20 months, survival rate was 84% in group 1 and 74% in group 2 (p = 0.11), including operative mortality of 7% and 13% (p = 0.42). Through effective volume reduction (LVEDVI 41%; LVESVI 49%) systolic function improved immediately after SVR (LVEF 27–39% in group 2, p < 0.05). Worsening of diastolic function was specifically observed after SVR within the first year (E/A-ratio 1.38– 1.74 cm/s, p = 0.02). Recurrent mitral regurgitation (p = 0.004) and secondary remodeling (p = 0.01) were major determinants of decreasing LV compliance. Clinical outcome in terms of cardiac events and survival was compromised by restrictive diastolic function (p = 0.02) and increased LV volumes (p = 0.04). Conclusion:SVRinadditiontocoronaryrevascularization and restrictive mitral annuloplasty results in significant clinical improvement in selected patients with advanced ischemic heart disease and severely dilated ventricles. SVRentailsimmediateimprovementofsystolicfunction, which remains sustained during short-term follow-up. Serial assessment of diastolic function is mandatory as LV compliance seems more sensitive to early changes induced by recurrence of mitral regurgitation and secondary ventricular dilation. Moreover, worsening of diastolic dysfunction should be timely recognized because of its adverse clinical impact. Ischemic cardiac disease • Surgical ventricular restoration • Heart failure 31 0 http://www.iscs.org.ir/journals/vol.2/no.4/49/

Original Article Objectives: The limited information available on thoracoscopic pulmonary vein isolation combined with ganglionated plexi ablation and the lack of studies regarding its effect on quality of life and physical capacity urged us to study its acute and long-term results in patients with atrial fibrillation. Methods: Forty-three patients (mean age 57.1 years) with symptomatic atrial fibrillation referred for thoracoscopic off-pump epicardial pulmonary vein isolation and ganglionated plexi ablation using radiofrequency energy were included. Results: The physical capacity improved significantly at 6-month follow-up compared with baseline (mean ± standard deviation, 165.2 ± 65 Watt versus 155.9 ± 57 Watt, P = .02). Quality of life (Short Form-36 health survey) significantly improved 12 months after surgery compared with baseline in all subscales except for bodily pain. The symptom severity questionnaire score decreased significantly from mean 15.2 ± 4.0 points to 10.7 ± 4.8 points (P = .02). Overall, 25 of 33 patients (76%) followed up for 12 months had no symptomatic atrialfibrillationrecurrencesoratrialfibrillationepisodes on 24-hour Holter recordings. The corresponding figures were 79% (19/24) for patients with paroxysmal atrial fibrillation, 100% (2/2) for persistent atrial fibrillation, and 57% (4/7) for permanent atrial fibrillation. The most common complication was bleeding events (9%) during pulmonary vein dissection. Conclusions: Epicardial off-pump pulmonary vein isolation combined with ganglionated plexi ablation improved quality of life, symptoms, and exercise capacity and therefore may be considered for patients with atrial fibrillation who fail endocardial pulmonary vein ablation or as a first-line procedure if left atrial appendage exclusion is warranted. Abbreviations and Acronyms AAD = antiarrhythmic drug; AF = atrial fibrillation; CT = contrast tomography; ECG = electrocardiogram; GP = ganglionated plexi; LAA = left atrial appendage; PV = pulmonary vein; QoL = quality of life; RF = radiofrequency; SSQ = symptom severity questionnaire Atrial firillation,Pulmonary Vein Isolation ,Quality of life,Radiofiegueney 30 31 http://www.iscs.org.ir/journals/vol.2/no.4/48/

Original Article Background: Postoperative atrial fibrillation is still a common complication in patients undergoing coronary artery bypass grafting. The aim of this study was to evaluate the effect of preoperative statin therapy on new onset of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. Methods: Of 8,946 patients undergoing isolated coronary artery bypass grafting at the Bristol Heart Institute from April 1996 to September 2006, 6,321 (70.6%) received preoperative statins. Of these, 2,152 patients (statin group) were matched to a control group (no statin) by propensity score analysis. Results: Preoperative characteristics, number of distal anastomoses, and the use of off -pump procedures were similar in both groups. Hospital mortality was 1.3% (56 patients) with no difference between the two groups. Postoperative atrial fibrillation was significantly higher in the statin compared with the no statin group (411, 19.5%, versus 336; 15.8% respectively; p = 0.002). In a multivariate regression analysis, age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.05), pulmonary disease (OR, 1.42; 95% CI, 1.12–1.82), history of paroxysmal atrial fibrillation (OR, 3; 95% CI, 2.13 to 4.19), preoperative angiotensin-converting enzyme inhibitor therapy (OR, 1.26; 95% CI, 1.07 to 1.49), ejection fraction less than 0.30 (OR, 1.71; 95% CI, 1.22 to 2.38), emergency operations (OR, 4.5; 95% CI, 2 to 10.12), and preoperative statin treatment (OR, 1.31; 95% CI, 1.11 to 1.55) were all independent predictors of postoperative atrial fibrillation. Conclusions: Preoperative statin is associated with a significantly higher incidence of postoperative atrial fibrillation compared with no statin treatment in patients undergoing isolated coronary artery bypass grafting. Coronary Artery disease,CABG,Atrial fibrillation,statin 30 0 http://www.iscs.org.ir/journals/vol.2/no.4/47/

Original Article Objective: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is the first treatment of choice with good short-term results. Only limited data are available concerning the long-term outcome after PEA. The purpose of this study is to evaluate the long-term survival and functional outcome after PEA with nearly 10 years experience. Method: In the period of December 1998 and December 2007 120 patients with CTEPH were referred to the St Antonius Hospital (Nieuwegein, The Netherlands) of whom 72 underwent PEA. The clinical data are collected retrospectively. Results: In-hospital mortality was (5/72) 6.9%. Since 2004 one patient died in the hospital (1/38, 2.9%). Two patients died during long-term follow-up with a median observation of 3 years. The overall 1-, 3-and 5-year survival rates were 93.1%, 91.2% and 88.7% respectively. Prior to surgery patients were in New York Heart Association functional class III (58) and IV (14) with a mean pulmonary vascular resistance of 572 ± 313 dynes s cm–5. The following data were compared before and after operation: mean pulmonary artery pressure (mPAP) decreased from 42 ± 11 to 22 ± 7 mmHg (p = 0.0001), NT-pro BNP improved from 1527 ± 1652 to 160 ± 3 pg/ml (p = 0.0001), 6 min walk distance (6MWD) from 359 ± 124 to 518 ± 11 m (p = 0.0001), and almost all patients returned to functional class I or II (p = 0.0001). Conclusion: Pulmonary endarterectomy for patients with CTEPH has shown a dramatic improvement of clinical status with excellent long-term survival. Pulmonary endarterectomy • Pulmonaryhypertension • Survival • Surgical outcomes 29 30 http://www.iscs.org.ir/journals/vol.2/no.4/46/

Original Article The optimal use of prophylactic intra-aortic balloon pump (IABP) to prevent postcardiotomy low cardiac output syndrome (LCOS) is still debated and poorly defined. The aim of this study was to evaluate whether prophylactic IABP reduces the rate of postcardiotomy LCOS and improves the early outcome in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting (CABG). From May 2004 to August 2007, 141 consecutive risk patients underwent CABG. Of these 38 (27%) received prophylactic IABP. The remaining 103 patientsunderwentoperationwithoutpreoperativeinsertion of the device. Prophylactic IABP patients were more likely to be younger (p<0.0001), had a recent myocardial infarction (p<0.0001), lower ejection fraction (p=0.006), and higher NYHA functional class (p=0.05). After risk- adjusting for propensity score, prophylactic IABP patients had a lower incidence of postcardiotomy LCOS (adjusted OR 0.07, p=0.006), postoperative myocardial infarction (adjusted OR 0.04, p=0.04), a shorter length of hospital stay (10.4±0.8 versus 12.2±0.6 days, p<0.0001) than those who did not receive IABP. This study shows that prophylactic IABP treatment for hemodynamically stable high-risk patients undergoing CABG may improve postoperative course reducing postcardiotomy LCOS, postoperative myocardial infarction and length of hospital stay. Intra-aortic balloon pump; Low output cardiac syndrome; High-risk patients 29 0 http://www.iscs.org.ir/journals/vol.2/no.4/45/

Original Article Objective: Application of extra-corporeal life support (ECLS) following pediatric cardiac surgery varies between different institutions based on manpower availability and philosophy towards ECLS utilization. We examined a large single institution experience with postoperative ECLS in children aiming to identify outcome predictors. Methods: Hospital records of all children who required postoperative ECLS at our institution were reviewed. Patients’ demographics, cardiac anatomy, surgical and ECLS support details were entered into a multivariable regression analysis to determine factors associated with survival. Results: Between 1990 and 2007, 180 consecutive children, median age 109 days (range: 1 day–16.9 years), required postoperative ECLS. Sixty-nine children (38%) had undergone palliative treatment for single ventricle pathology.ECLSsupportwasrequiredforfailuretoseparate from cardiopulmonary bypass (n = 83) or for postoperative low cardiac output state (n = 97). Forty-eight patients (27%) received rescue extra-corporeal membrane oxygenation (ECMO) support during active chest compression for refractory cardiac arrest. Under ECLS support, 37 patients required surgical revision and 20 received orthotopic heart transplantation. One hundred and nine patients (61%) survived >24 h following ECLS discontinuation and 68 (38%) were discharged alive. Hospital survivors required shorter ECLS support duration compared to non- survivors (median 3 vs 5 days, respectively, p = 0.05) however survival occurred after up to 16 days of ECLS support. ECLS indication (OR: 0.85 for failure to separate from bypass vs postoperative low cardiac output 95% CI (0.47–1.56), p = 0.62) and rescue ECMO (OR: 0.63 for rescue ECMO vs not 95%CI (0.32–1.24), p = 0.18) were not associated with risk of mortality. In a multivariable logistic regression model, neurological complications (p = 0.0007), prolonged ECLS duration (p = 0.003), repeat ECLS requirement (p = 0.02), renal dysfunction (p = 0.04) and not performing heart transplantation (p = 0.04) were significant factors for hospital death. Conclusion: ECLS plays a valuable role in children with low cardiac output state following cardiac surgery. More than one third of those patients, including young neonates, older children, patients with single ventricle, or those requiring rescue ECMO can be salvaged. Although prognosis worsens with prolonged ECLS duration, survival can be noted up to 16 days of support. Heart transplantation is often an important ECLS exit strategy and should be considered early in selected children. Patients’ survival could improve if renal and neurological complications are avoided. Congenital heart disease • Cardiac arrest Extra-corporeal life support • Single ventricle 29 0 http://www.iscs.org.ir/journals/vol.2/no.4/44/

Original Article Objectives: The study was designed to assess whether diazoxide-mediated cardioprotection might be used in human subjects during cardiac surgery. Methods: Forty patients undergoing coronary artery bypass grafting were randomized to receive intermittent warm blood antegrade cardioplegia supplemented with either diazoxide (100 μmol/L) or placebo (n = 20 in each group). Mitochondria were assessed before and after ischemia and reperfusion in myocardial biopsy specimens. Myocardial oxygen and glucose and lactic acid extraction ratios were measured before ischemia and in the first 20 minutes of reperfusion. Hemodynamic data were collected, and troponin I, creatine kinase–MB, and N-terminal prohormone brain natriuretic peptide levels were measured. All outcomes were analyzed by using mixed- effects modeling for repeated measures. Results: No deaths, strokes, or infarcts were observed. Patients received, on average, 36.2 ± 1.2 mg of diazoxide and 37.3 ± 1.9 mg of placebo (P = .6). Diazoxide added to cardioplegia prevented mitochondrial swelling (8899 ± 474 vs 9273 ± 688 pixels before and after the procedure, respectively; P = .6) compared with that seen in the placebo group (8474 ± 163 vs 11,357 ± 759 pixels, P = .004). No oxygen debt was observed in the diazoxide group. Glucose consumption and lactic acid production returned to preischemic values faster in the diazoxide group. The following hemodynamic parameters differed between the diazoxide and placebo groups, respectively, in the postoperative period: cardiac index, 3.0 ± 0.09 versus 2.6 ± 0.09 L • min–1 • m–2 (P = .002); left cardiac work index, 2.81 ± 0.07 versus 2.31 ± 0.07 kg/m2 (P < .001); oxygen delivery index, 420 ± 14 versus 377 ± 13 mL • min–1 • m–2 (P = .03); and oxygen extraction ratio, 29.3% ± 1.1% versus 32.6% ± 1.1% (P = .02). Postoperative myocardial enzyme levels did not differ, but N-terminal prohormone brain natriuretic peptide levels were lower in the diazoxide group (120 ± 27 vs 192 ± 29 pg/mL, P = .04). Conclusions: Supplementing blood cardioplegia with diazoxide is safe and improves myocardial protection during cardiac surgery, possibly through its influence on the mitochondria. Abbreviations andAcronymsAXC = aortic crossclamping; CK-MB = creatine kinase–MB; CPB = cardiopulmonary bypass; KATP = adenosine triphosphate–sensitive potassium; NT-proBNP = N-terminal prohormone brain natriuretic peptide; O2ER = oxygen extraction ratio myocardial Protection,Cardiac Surgery,Cardioplegia,Cardiopulmonary bypass 27 0 http://www.iscs.org.ir/journals/vol.2/no.4/43/

Original Article Objective: Cardioprotective properties of recombinant human Erythropoietin (rhEpo) have been shown in in vivo regional or ex vivo global models of ischemia–reperfusion (I/R) injury. The aim of this study was to characterize the cardioprotective potential of rhEPO in an in vivo experimental model of global I/R approximating the clinical cardiac surgical setting and to gain insights into the myocardial binding sites of rhEpo and the mechanism involved in its cardioprotective effect. Methods: Hearts of donor Lewis rats were arrested with cold crystalloid cardioplegia and after 45 min of cold global ischemia grafted heterotopically into the abdomen of recipient Lewis rats. Recipients were randomly assigned to control non-treated or Epo-treated group receiving 5000 U/kg of rhEpo intravenously 20 min prior to reperfusion.At 5 time points 5–1440 min after reperfusion, the recipients (n = 6–8 at each point) were sacrificed, blood and native and grafted hearts harvested for subsequent analysis. Results: Treatment with rhEpo resulted in a significant reduction in myocardial I/R injury (plasma troponin T) in correlation with preservation of the myocardial redox state (reduced glutathione). The extent of apoptosis (activity of caspase 3 and caspase 9, TUNEL test) in our model was very modest and not significantly affected by rhEpo. Immunostaining of the heart tissue with anti-Epo antibodies showed an exclusive binding of rhEpo to the coronary endothelium with no binding of rhEpo to cardiomyocytes. Administration of rhEpo resulted in a significant increase in nitric oxide (NO) production assessed by plasma nitrite levels. Immunostaining of heart tissue with anti-phospho- eNOS antibodies showed that after binding to the coronary endothelium, rhEpo increased the phosphorylation and thus activation of endothelial nitric oxide synthase (eNOS) in coronary vessels. There was no activation of eNOS in cardiomyocytes. Conclusions: Intravenous administration of rhEpo protects the heart against cold global I/R. Apoptosis does not seem to play a major role in the process of tissue injury in this model. After binding to the coronary endothelium, rhEpo enhances NO production by phosphorylation and thus activation of eNOS in coronary vessels. Our results suggest that cardioprotective properties of rhEpo are at least partially mediated by NO released by the coronary endothelium. Erythropoietin • Myocardial ischemia– reperfusion injury 27 0 http://www.iscs.org.ir/journals/vol.2/no.4/42/

Original Article Objective: Right ventricular failure during left ventricular assist device (LVAD) support can result in severe hemodynamic compromise with high mortality. This study investigated the acute effects of cavopulmonary anastomosis on right ventricular loading and LVAD performance in a model of severe biventricular failure. Methods: LVAD support was performed by means of centrifugal pump implantation in 14 anesthetized dogs (20–30 kg) with severe biventricular failure obtained by ventricularfibrillationinduction.Animalswererandomized to be submitted to classical cavopulmonary anastomosis (Glenn shunt) or to control group and were maintained under LVAD support for 2 h. Left and right atrial, right ventricular and systemic pressures were monitored, while total pulmonary flow was simultaneously recorded by transonic flowmeters located on the superior vena cava and pulmonary trunk. Blood gas and venous lactate determinations were also obtained. Results: Ventricular fibrillation maintenance resulted in acute LVAD performance impairment after 90 min in the control group, while animals with Glenn circuit maintained normal LVAD pump flow (55 ± 13 ml kg–1 min–1 vs 21 ± 4 ml kg–1 min–1, p < 0.001) and better peripheral perfusion (blood lactate of 29 ± 10 pg/ml vs 46 ± 9 pg/ml, p < 0.001). Left and right atrial pressures did not change significantly, while right ventricular pressure was lower in animals with Glenn circuit (13 ± 3 mmHg vs 22 ± 8 mmHg, p = 0.005). Right ventricular unloading with Glenn shunt also resulted in superior total pulmonary flow (59 ± 13 ml kg–1 min–1 vs 17 ± 3 ml kg–1 min–1, p < 0.001). Conclusion: The concomitant use of cavopulmonary anastomosis during LVAD support in a model of severe biventricular failure limited right ventricular overloading and resulted in better hemodynamic performance. Circulatory support • Assisted circulation Biventricular failure • Cavopulmonary anastomosis Right ventricle 26 0 http://www.iscs.org.ir/journals/vol.2/no.4/41/

Original Article A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the bicaval heart transplantation technique is superior to biatrial orthotopic heart transplantation (OTH). Altogether, 175 papers were found using the reported search, of which 20 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concludethatmany papers have documented the superiority of the bicaval technique over the biatrial technique for short-term outcomes. A meta-analysis of 41 papers on this topic found significant benefits for early atrial pressure, tricuspid valve regurgitation, return to sinus rhythm and even perioperative mortality. But for longer-term outcome, the largest series of 11,931 patients found no difference in survival between the two groups and the meta-analysis found no mortality differences at 1 or 3 years. The bicaval technique is also more demanding technically and has a slightly longer bypass and ischemic time. The United Network for Organ Sharing (UNOS) database showed that in 2005 in the USA the bicaval technique has now become more popular than the biatrial technique (1083 procedures versus 806). Evidence-based medicine; Orthotopic transplantation; Bicaval anastomosis; Biatrial anastomosis; Survival; Arrhythmia 26 0 http://www.iscs.org.ir/journals/vol.2/no.4/40/

Original Article Objective: Little information is available about surgical outcomes in patients with multivalvular endocarditis. The aim of this article is to review the 21-year experience with surgical treatment of patients with multivalvular endocarditis at our institution and, in particular, to determine the incidence, pathologic status, diagnosis, surgical strategies, and outcomes of patients with this disease. Methods: From January 1986 to December 2006, a total of 48 patients (40 men, 8 women), with a mean age of 42 ± 12 years, underwent surgery for multivalvular endocarditis. Endocarditis was active in 32 patients and healed in 16. Preoperative transthoracic echocardiographic evaluation was performed in all 48 patients with addition of transesophageal echocardiography in 22 (45.8%). Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (40/48 patients). Triple or quadruple valve involvement was found in 1 and 2 patients, respectively. Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors for early and late survival were determined. Results: In only 24 (50.0%) patients was multivalvular endocarditis diagnosed by preoperative transthoracic echocardiography; 17 (77.3%) patients had multivalvular endocarditis confirmed by preoperative transesophageal echocardiography. The 30-day hospital mortality was 12.5% (n = 6). Preoperative renal failure, New York Heart AssociationclassIV,andemergencysurgerywereidentified as independent risk factors for hospital mortality. Overall long-term survival was 74% ± 6% at 5 years and 62% ± 3% at 10 years. Multivariate analysis revealed that renal failure and recurrent endocarditis were associated with increased late mortality. Ten-year freedom from recurrent endocarditis was 74% ± 5% and 10-year freedom from reoperation was 73% ± 6%. Conclusions: In our institution, multivalvular endocarditis was diagnosed by transthoracic echocardiography in only half of the patients. Intraoperative transesophageal echocardiography provided a more effective means to identify this disease. Radical resection of all infected tissues for patients with multivalvular endocarditis and additional intraoperative interventions, depending on the intraoperative pathologic condition, produced satisfactory in-hospital and long-term results, similar to those in patients with a single infected heart valve. Abbreviations and Acronyms CHD = congenital heart disease; CI = confidence interval; MVE = multivalvular endocarditis; NVE = native valve endocarditis; OR = odds ratio; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography Heart Valve,Endo Carditis,Valve Surgery 25 26 http://www.iscs.org.ir/journals/vol.2/no.4/39/

Original Article Background: The surgical treatment of ischemic mitral regurgitation (MR) usually involves implantation of an annuloplasty ring. We compared results of mitral valve repair using a flexible or a rigid annuloplasty ring in patients with ischemic MR undergoing coronary artery bypass graft surgery. Methods: There were 169 patients. A flexible ring was implanted in 117 and a rigid ring in 52. Age and clinical profile, degree of left ventricular dysfunction, and degree of MR (mean 3.2) were similar between groups. Results: Operative mortality was 9% in each group. Follow- up (58 ± 30 months for flexible group and 14 ± 7 months for rigid group) was available for 91%. For the flexible and rigid ring groups, respectively, mean New York Heart Association functional class was 1.9 and 1.6, with 33% and 14% in classes III to IV (p = 0.03); mean MR grade was 1.25 and 0.7 (p = 0.006). There was no difference in left ventricle function or dimensions. At follow-up, 29 patients (34%) in the flexible group had residual MR of moderate degree or greater compared with 6 (15%) in the rigid group (p = 0.03). Mean tricuspid incompetence gradient was 39 and 34 mm Hg (p = nonsignificant); however, the degree of reduction was greater in the rigid group (p = 0.001). Late mortality was observed in 32 patients, all in the flexible group. Conclusions: Clinical and hemodynamic results are better with rigid mitral annuloplasty rings compared with flexible rings. That result may be due to ring design, which dictates not only the annular diameter but also annular configuration. Longer follow-up is needed to determine differences in survival Mitral Valve,Ischemic MR,Ring Annuloplasty 25 0 http://www.iscs.org.ir/journals/vol.2/no.4/38/

Original Article <p><strong>&nbsp;</strong></p> Aortic Valve,mitral valve,valve replacement,mitral valve repair 24 0 http://www.iscs.org.ir/journals/vol.2/no.4/37/

Original Article We propose to analyse the long-term follow-up in patients older than 65 years of age who received a mechanical valve in the aortic position, using death and prosthetic-related complications as endpoints. From April 1988 to December 1995, 144 consecutive patients 65-75 years of age (mean 67.7±2.5) were enrolled. Total duration of follow-up was 1663 patient-years (median 13.0 years) and was complete for 99% of the patients. Thirty-day mortality was 1.4% (n=2). At the end of the study, 77 patients (53.8%) were alive, with ages ranging from 77 to 91 years (mean 82.1±3.2 years). The overall 5-, 10-and 15-year actuarial survival was 87.4%±3.0, 67.7%±4.3 and 58.5%±4.5, respectively. Freedom from stroke was 93.3±3.1%, 84.6±3.3% and 71.7±4.5%, respectively, after identical periods. Freedom from major bleeding was 97.2±1.1%, 90.4±3.5% and 86.4±4.0%, respectively. Freedom from endocarditis was 95.7±2.3%, 95.0±2.1% and 94.4±2.5%, respectively, and freedom from reoperation was 98.0±1.2%, 97.6±1.3%, 96.9±2.4% and 96.4±2.6%, respectively. Freedom from major valve-related events was 87.7±2.6%, 73.9±3.4% and 61.5±4.6%, respectively. Nearly two-thirds of the patients were alive and free from major adverse valve-related events. Hence, we consider implantation of a mechanical prosthesis in elderly patients safe and appropriate, but the choice must be tailored for each specific patient. Aortic valve replacement; Elderly; Mechanical prostheses; Bioprostheses 24 0 http://www.iscs.org.ir/journals/vol.2/no.4/36/

Original Article Introduction: Aorto-pulmonary window is a very rare Malformation which accounts for about 0.15% of all cardiac anomalies. There is no tendency for AP windows to close spontaneously. The natural history of infants with large AP windows is as unfavorable rarely they survive to childhood and those who survive beyond early life have important pulmonary vascular disease (1). The Richardson classification system for aorto-pulmonary window includes simple defects between the ascending aorta and pulmonary trunk (type I), defects extending distally to include the origin of the right main pulmonary artery (type II), and anomalous origin of the right main pulmonary artery from the ascending aorta with no other aorto-pulmonary communication (type III). Material and Methods: We reviewed our cases of aorto-pulmonary window who underwent surgical repair From 1992 to 2007 at Sahid Rajee Heat center, Tehran, Iran. There were 30 children with male to female ratio of 2:1 .We evaluated demographic information of the patients.We used different operative techniques . The approach for AP Window repair was ligation without CPB in two cases, division and suturing using CPB in one patient, trans-window in 17 (PTFE patch in16; Dacron in 1), trans-aortic in 9 (in 8 PTFE patch, in one simple suturing) and trans-pulmonary in 2 (both with PTFE) Among 15 patients with associated cardiac anomalies, 13 (87%) underwent single stage repair with the IAA repair was the most common (2 cases) .Factors such as cross-clamp and bypass time, mortality, early and late morbidity, ICU stay, hospital stay, duration of ventilator support were compared between groups with various methods of repair using “SPSS 16”. Resullts: In among 30 patients male to female ratio was 2:1 .Mean age of the opatients was 28± 9 months ;range 2-90 months,weight 8.6±4.6;range 2-17 kg . Most patients (73%) had sub-systemic or systemic pulmonary hypertension (23% and 50% respectively) .Morphology of Ap windows was type I (87%, n=26), type II (10%, n=3) distal and one type III (3%), This agree with other reportsres. 63% of patients were symptomatic, most commonly dyspnea and 43% were in heart failure on admission. Preoperative EF was 0.66 ± 0.07 which increased to 0.75 ± 0.07 post-operatively apparently duo to elimination of shunt and resultant increase in forward flow of aorta. Preoperative pulmonary artery pressure was 63 ± 13 mm Hg. 19 (63%) of patients had associated cardiac anomalies most frequently various forms of Aortic stenosis (23%) fallowed by interrupted aortic arch (IAA), coronary anomalies and VSD (each about 7%). In most other series IAAhas been most common associated anomaly (6), (7). The overall in-hospital mortality was 10% (3 patients), two of whom had associated anomaly, one had undergone arterial switch operation for TGA who couldn’t be separated from CPB, and the other one had simultaneous repair for interrupted aortic arch. The mortality was no different among patients with or without associated anomaly (10% each). Among the 27 survivors, the mean ICU stay was 4.4 days (range 3 -12 days) and the mean post-operative hospital stay was 10.7 days (range 7 -16 days). Early complications were bleeding (two cases), pneumonia (one) and CVA (one). Mean follow-up was 49 months (range 2 – 280 months) and there was no re-operation or late death. There were 4 cases of residual AP Window detected by echocardiography; none of them required re-intervention. Among patients with residual AP Window two cases were seen with banding technique (100%) one with trans-aortic patch repair (11%) and one case with trans-window patch repair (5%). Discussion: An aorto-pulmonary window is a communication between the pulmonary artery (PA) and the ascending aorta in the presence of two separate semilunar valves. There is no tendency for AP Windows to close spontaneously [8] Since the early 1990s, diagnosis has relied exclusively on two-dimensional echocardiography [9] but type II and III lesions are difficult to differentiate from PDA [10]. Cardiac catheterization and cineangiography with retrograde aortography is done in infants 6 months of age for evaluating the presence of irreversible pulmonary vascular disease and in case of complex APW for delineating the exact morphology. In our series in 27% (8) of patients the diagnosis was made only through echocardiography, remainder of the cases was diagnosed via both echocardiography and angiography.Using multivariate analysis, we assessed the effects of (1) patient related factors (age, sex, weight and type of aorto-pulmonary window) and (2) procedural factors (type of approach) on post-operative course (ICU stay, Post-operative hospital stay, duration of ventilator support and post-operative EF). Age ,sex and weight had no clear impact on post operative course. As mentioned earlier the overall in-hospital mortality was 10% (3 patients). The reported mortality among other series ranged from 7.6% to 27%).The mortality was no different among patients with or without associated anomaly (3% each). Also there was no difference among various methods of repair in respect of morbidity, ICU stay; ventilator support and post operative EF . Conclusion: In our view Trans aortic or transwindow repair is the procedure of choice for APW repair and, simple ligation without CPB should be avoided due to the possibility of residual APW and distortion of pulmonary artery. Aortopulmonary window,Transaortic repair,Cardiopulmonary bypass 18 23 http://www.iscs.org.ir/journals/vol.2/no.4/35/

Original Article Background: Post-operative bleeding is one of the Challenging issues in cardiacsurgery. The Excessive bleeding and need for transfusion of blood products may increases the patients’ mortality and morbidity. Although use of antifibrinolytics has long been the issue of interest but recently according to some reports of sudden death after use of aprotinin has encountered great limitations. So we decided to find an alternative drug for aprotinin. Methods and Materials: This study was performed as a Double blind Randomized clinical traial. Three hundred patients underwent open heart surgery using CPB to Shahid Rajaee Heart Center. The patients were divided into 3 groups; each containing 100 patients. Group A Amicar (Caproamin) , group B (Tranexamic acid) and group C (Control). The mean age was 56.5 yr. (Ranged 16-79). 65.3% were male and 85.7% underwent CABG. Need for blood and blood products transfusion in operating room, ICU & ward, as well ad post-op drainage volume during 6, 12, 24 hours were evaluated. The probable post-op complications including post-op myocardial infarction or CNS, renal complications were also recorded. Results: The average volume of hemorrhage in group A was 427 cc, 558 cc in group B & 659 cc, in group C, but these differences were not significant statistically (P=0.55). In group A 46% of patients need 1-8 unit of blood, in group B this rate was 60% and in group C was 69% (P=0.093). Prevalence of post op MI was zero in group A 2% in group B and 3% in group C (P=0.377). Incidence of Re- explorationwas 4% in group A, 5% in group B & 6% in group C (P=0.810). The length of hospital stay was the least in group A and was the most in group B, but this difference was also not as significant (P=0.964) Comment: Antifibrinolytics, particularly Caproamin can play a role in decreasing post operative mediastinal bleeding, especially non surgical bleeding. Both Transamin and Caproamin are safe and do not increase thromboembolic events and other complications. These drugs do not cause significant reduction in volume of postoperative bleeding and transfusion requirements in OR and ICU, but when just CABG cases are considered, Caproamin causes significant reduction in post op hemorrhage and as a result reduction in transfusion requirements of blood products. CABG, Mediastinal bleeding, Antifibrinolytic, Open Heart Surgery 13 17 http://www.iscs.org.ir/journals/vol.2/no.4/34/

Original Article <p>Abstract: Introduction: Coronary artery disease A significant metabolic derangement occurs in the ischaemic-reperfused heart of patients undergoing coronary artery bypass surgery using cold blood cardioplegia . It has been reported that up to one forth of deaths after coronary artery bypass grafting surgery may be caused by Reperfusion injury especially in patients with higher NYHA classes. There are evidences that in adult cardiac operations, a warm cardioplegic reperfusate (hot shot) before removing the aortic cross-clamp improves postbypass myocardial function and metabolic recovery . We randomly assigned 41 consecutive patients undergoing primary, elective CABG into two groups; TWBC Group who received Terminal Warm Blood Cardioplegia just before removing of Aortic cross clamp (n=24) and second group (Control) did not received TWBC (n=17). Among patients in CONTROL group 41% (95% CL: 19-62%) received at least one inotrope, but only 17% (95% CL:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;0 - 35%) of patients in TWBC group did so (p = 0.085). Also in respect to EF there was superiority in TWBC group only in patients with low pre operative EF. There was higher rate of spontaneous beating in TWBC group (21 of 24 or 88%) versus Control group (12 of 17 or 70%; P&lt;0.1). Conclusion: it seems prudent to routinely use Terminal Warm Blood Cardioplegia in patients undergoing coronary bypass graft especially in those with reduced ventricular function.</p> Cardioplegia, CABG, Myocardial Protection 9 12 http://www.iscs.org.ir/journals/vol.2/no.4/33/

Original Article Background: Postoperative pain remains as a challenging case despite improvement of analgesic techniques. It may also increase the rate of morbidity and even mortality. Local anesthesia may decrease the consumption of opioids and its potential side effects. This study was aimed to show the role of local anesthesia in post-sternotomy pain. Methods: This prospective randomized clinical trial includes 40 candidates for elective coronary artery bypass graft (CABG) surgery. Patients with diabetic mellitus and other major co-morbidities were excluded. In group A (20 patiens) Bupivacaine 0.25% was continuously infused into subcutaneous tissue using the ON-Q system (I-flow Corporation, Lake Firest CA, USA) (2ml/h for 72h). Group B patients did not receive local anesthetics. The intensity of pain in was measured using Visual Analogue Scale (0-10). Need for narcotics or other analgesics, hemodynamic and arterial blood gas profiles were also recorded. Results: Both groups were similar regarding age, sex, body mass index, smoking and drug addiction and operative characteristics. The mean visual analogue scale (VAS) was significantly lower in G.A than G.B (2.1+/-1.7 versus 4.3+/- 2.7) (P=0.005). Narcotics requirement in G.A had decreased 25% compared to G.B (P= 0.041) but the mean doses of opioids consumption had no significant difference in two groups. Most of the patients in G.A (85%) were fully satisfied from his pain control, while this rate was only 45% in G.B (P= 0.029). Regarding other post- operative complications, both groups were identical and no significant difference was observed. Days of stay in hospital was reduced 1.4 days in average which is not significant (P=0.06). Drug addicts required higher doses of narcotics. Conclusion: Continuous local infusion of Bupivacain with ON-Q pump system can be useful and safe for pain management after median sternotomies. Bupivacaine not only reduces the pain intensty, but also reduces the consumption of opioids and other analgesics when compared to the control group. It also seems that this method may reduce the length of hospitalization and hence the hospital charges. Pain, CABG, Local Anesthesia, ON-Q Pump, Bupivacaine 3 8 http://www.iscs.org.ir/journals/vol.2/no.4/32/