Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension: a report of 15 cases

Chronic thromboembolic pulmonary hypertension [CTEPH] is a serious and underdiagnosed disorder with significant morbidity and mortality. It is thought to result from single or recurrent pulmonary thromboemboli arising from the sites of venous thrombosis, often from the lower limbs. Surgical correction of anatomical obstructions [endarterectomy of pulmonary artery] is the treatment of choice in these patients, and the patients outcomes are good. The mortality rate in some centers is about 5%, but in others it is up to 30%. We started pulmonary endarterectomy in Shaheed Rajaie Heart Center [RHC] in Iran four years ago. Pulmonary thromboendarterectomy is performed under hypothermia and total circulatory arrest with cardiopulmonary bypass. All patients are evaluated in our hospital for known risk factors of deep vein thrombosis and pulmonary emboli. Right heart catheterization and measurement of pulmonary artery pressure and vascular resistance are performed in some of the patients and left heart catheterization in those who are over 45 years of age. CT angiography of the pulmonary artery with multi-slice CT scan is done in all patients before and after endarterectomy. Patient selection for successful endarterectomy is based on CT angiography and perfusion lung scan with consideration of pulmonary vascular resistance in some cases. During a 4-year period, 15 patients [5 female and 10 male] underwent this type of surgery in RHC. Their mean age was 35.87 [min. 18, max. 55] years old. The mean pulmonary artery systolic pressure by echocardiography was 87.60 mmHg [min. 55mmHg, max. 140 mmHg, SD 23.26 mmHg] and the mean pulmonary artery pressure was 46.43mmHg [min. 23 mmHg, max. 60 mmHg, SD 11.70 mmHg]. Mean surgery time was 5.33 hours [min. 4hrs, max. 14 hrs, SD. 2.46 hrs], mean bypass time was 138 minutes [min. 84, max. 220, SD=43.28 minutes], mean intubation time was 49.88 hours [min. 7 hrs, max. 216 hrs, SD 61.66 hrs], and intensive care unit stay time was 5.43 days [min. 3, max. 9, SD=1.98]. Two fatalities occurred due to bleeding and shock. The mortality rate was 20%. IVC filters were placed in a minority of the patients who had clear-cut evidence of lower extremity deep vein thrombus as a cause of pulmonary thromboembolic events. Pulmonary endarterectomy is the treatment of choice in CTEPH with an acceptable mortality rate and a good prognosis. It is possible to perform this procedure without recourse to more sophisticated evaluations with an acceptable mortality rate in patients who have segmental lobar or main pulmonary artery organized clot

Non-invasive assessment of left ventricular end-diastolic pressure in patients with chronic aortic regurgitation, comparison of the sensitivity and specificity of CW doppler echocardiography with angiography

Left ventricular end diastolic pressure could be estimated collectively using various measures of mitral valve and pulmonary venous flow velocities. In patients with aortic regurgitation, the AR velocity reflects the diastolic pressure difference between the aorta and the left ventricle. We sought to predict the left ventricular end diastolic pressure by a new Doppler index as aortic regurgitation peak early to late diastolic pressure gradient ratio. Fifty three patients with at least moderate aortic regurgitation were enrolled in this study. Physical examination, electrocardiography and echocardiography were performed one day before cardiac catheterization. The severity of AR was graded according to the recommendations of American society for echocardiography. The pressure half time, aortic regurgitation early diastolic velocity, aortic regurgitation early diastolic pressure gradient, aortic regurgitation end diastolic velocity, aortic regurgitation end diastolic pressure gradient, and early diastolic to end diastolic pressure gradient ratio of averaged three beats were measured and recorded. The results from cardiac catheterization and echocardiography were compared. The early diastolic to end diastolic pressure gradient ratio was very accurate [80%] for determining the left ventricular end diastolic pressure [P =0.01]. An early diastolic to end diastolic pressure gradient ratio of 1.5 has a sensitivity of 96% and a specificity of 32% for left ventricular end diastolic pressure 12 mmHg was higher than 2.0, with a sensitivity of 71% and specificity of 96% We found no significant correlation between the left ventricular end diastolic pressure with either left ventricular ejection fraction or aortic regurgitation severity in cardiac catheterization [P =0.5]. Doppler echocardiography is a viable alternative of cardiac catheterization for determination of the left ventricular end diastolic pressure. The early diastolic to end diastolic pressure gradient ratio is a simple, easy and new method for assessment of the LVEDP in patients with severe chronic aortic regurgitation

Evaluation of regional myocardial systolic function in the early stage of acute myocardial infarction by strain rate imaging

We sought to evaluate the impact of different therapeutic strategies on longitudinal regional myocardial systolic function in the early phase of acute myocardial infarction using strain rate imaging. A total of 38 patients [34 males], with first acute myocardial infarction [AMI] were evaluated. Our patients were divided into 3 groups according to the kind of therapy. The mean age of the patients was 55 +/- 9.4 years [range: 39- 75 years]. Mean left ventricular ejection fraction [LVEF] in the patients was 41 +/- 10.7%. Primary percutaneous coronary intervention [PCI] was performed in 10 patients. Sixteen patients were treated by thrombolytic therapy using streptokinase [SK] and 12 were followed-up conservatively. All patients underwent a comprehensive echocardiography study including SR imaging within 3- 5 days after AMI. The parameters measured included peak systolic strain [peak epsilon] and strain rate [SRs], end-systolic strain [epsilon es], post systolic shortening [PSS], time to peak systolic strain rate [tSRs], time to end of shortening [teSRs], post systolic strain [PS epsilon], post-systolic strain index [PSI], PSS ratio [PSS/ epsilon [Max]] and peak postsystolic strain rate [SRPSS]. There was not any association either between WMSI and ta [P=0.4], or MI location and PSS ratio [P=0.13]. But there was an inverse relationship between WMSI and mean SRS, especially when WMSI was more pronounced. A significant relationship was found between t epsilon epsilon and teSRs with the kind of therapy [shorter in PCI group [P= 0.04]. Using a simple linear regression model, no association was found between PSS ratio and SRs [a=0.056, P =0.70], PSI and teSRs [beta= -0.772, P=0.12]. Simple linear regression model showed a weak but significant relationship between PSI and Median t epsilon [beta = -0.851, P =0.04; r =0.33]. Our study showed that PCI resulted in early recovery of regional systolic function of infarcted myocardium during the early stage of acute myocardial infarction

Quantification of aortic regurgitation severity by left ventricular to right ventricular stroke volume ratio

Echocardiography is the most common test used for the evaluation of aortic regurgitation [AR]. However, the role of echocardiography as an available and inexpensive method in the quantification of AR by the left ventricle to right ventricle stroke volume ratio [LV/RV SV ratio] has not been completely investigated. Between June 2005 and December 2007, 132 consecutive patients with AR [mean age: 44.7 +/- 14.6 years, 52.3% male] were enrolled in the study. All the patients underwent echocardiography; and aortography, if indicated, was performed as well. Fifty-two percent of the patients had severe AR. There was almost a perfect agreement between echocardiography and cardiac catheterization in determining the severity of AR [Kappa=0.81]. Associated valvular disease was found in 81.8% of the patients, the most common disease being mitral regurgitation [61%]. The results of our bivariate and multivariate analyses showed a significant relation between the LV/RV SV ratio and the AR severity via either echocardiography or cardiac catheterization [both P=0.001]. The receiver operating characteristic [ROC] curve analysis showed that the LV/RV SV ratio was very accurate in the detection of severe AR utilizing cardiac catheterization as the gold standard [AUC=0.71]. The cut point value of the LV/RV SV ratio

Health state valuation in Iran: an exercise on cardiovascular diseases using visual analogue scale method

Disability Weights [DWs] are main components for computing summary measure of population health [SMPH] and economic studies. They are specific for each community, but there are no previous studies in Iran. In this study, we investigated the feasibility of health state valuation [HSV] in Iranian population. Twelve cardiologists in 3 sessions of expert panels, defined 25 states, related to cardiovascular diseases [3 major and 22 specific diseases]. From January to March 2008, 80 persons in 4 groups including: physicians, patients, patients' families and general publics [each group 20], were interviewed and valuated the states, using visual analogue scale [VAS] method. SPSS[Registered] 15 for window[Registered] [SPSS Corporation, Chicago, Illinois] was used for statistical analysis. Data showed that the defined health states had various severities. All the 4 groups ranked the "3 major-diseases" and "very-mild" and "very-severe" states, similarly. Non-physicians were not able to differentiate among "valvular-diseases" and "pacemakers" properly. The reliability of responses was acceptable. VAS is an appropriate and reliable method for HSV in Iranian population. Non-physicians' opinions can be consider in major cardiac diseases. Valuation of more specific situations must perform by physicians

Comparison of transesophageal echocardiographic assessment of right and left atrial appendage functions

To define right atrial appendage functional parameters and comparing them with those of left atrial appendage. A consecutive series of 154 patients [76 males and 78 females] with mean age of 42 years were referred for transesophageal echocardiography. Ejection and filling velocities of right and left atrial appendages were measured at 120 and 70 degrees respectively. The left and right ventricles size and function, right atrial size, tricuspid regurgitation severity, and pulmonary artery systolic pressure were prospectively measured and calculated during transthoracic echocardiography. Mean right and left atrial appendages velocities were 42 +/- 18 cm/s and 50 +/- 26 cm/s respectively [PV<0.001]. Statistically significant positive association [PV<0.001] was found between right atrial appendage velocity and right ventricle ejection fraction and statistically negative relationship was observed between right atrial appendage velocity and smoke pattern [PV<0.001]. Also, the results suggested marginally significant associations between right atrial appendage velocity and right atrium size [PV = 0.05] and pulmonary artery systolic pressure [PV = 0.07]. It was also found that right atrial appendage measures were relatively independent on right ventricle size and tricuspid regurgitation severity. Our study showed right atrial appendage measures were relatively dependent on right ventricle function, right atrium size and pulmonary artery systolic pressure and relatively independent on right ventricle size and tricuspid regurgitation severity. In patients with right atrium smoky pattern right atrial appendage velocity was significantly reduced

Correlation of right ventricular DP/DT with functional capacity and RV function in patients with mitral stenosis

Evaluation of right ventricular [RV] contractility and systolic function in patients with right sided heart disease is an essential component of clinical management. The aim of this study was to assess RV systolic function by qualitative and quantitative methods and compare it to rate of ventricular pressure change during the isovolumic contraction period [dP/dt] as RV contractility index in patients with rheumatic mitral stenosis. In 56 consecutive patients with moderate to severe mitral stenosis, RV systolic function, RV dP/dt and dP/dt/Pmax, were calculated and compared. There was significant correlation between RV dP/dt and RV function [P < 0.001] and between RV dP/dt and New York Heart Association [NYHA] functional capacity [P < .001]. The mean of dP/dt was decreased with increasing severity of RV dysfunction [mean dP/dt was 648 +/- 159 for normal RV function, 592 +/- 126 for mild RV dysfunction, 319 +/- 146 for moderate RV dysfunction and 166 +/- 150 for severe RV dysfunction] Severity of tricuspid regurgitation and pulmonary hypertension had no significant effect on RV dP/dt and RV function. RV dP/dt/Pmax had also significant relationship with RV function and functional capacity [P < 0.001]. Measurements of dP/dt and dP/dt/Pmax, are practical methods for estimating RV contractility and results have a good correlation with RV systolic function and functional capacity

Diagnostic accuracy of Multi-Slice Computed Tomographic [MSCT] angiography in the detection of cerebral aneurysms

Multislice computed tomographic [MSCT] angiography is a rapid and minimally invasive method for the detection of intracranial aneurysms. The purpose of this study was to compare MSCT angiography with digital subtraction angiography [DSA] in the diagnosis of cerebral aneurysms. In this cross sectional study we evaluated 111 consecutive patients [42[37.8%] male and 69[62.2%] female], who were dmitted under clinical symptoms and signs, suggestive of harboring an intracranial aneurysm by using a four detector MSCT angiography. Then we compared results of MSCT angiography with DSA results as a gold standard method. DSA was performed by bilateral selective common carotid artery injections and either unilateral or bilateral vertebral artery injections, as necessary. MSCT angiography images were interpreted by one radiologist and DSA was performed by another radiologist who was blinded to the interpretation of the MSCT angiograms. The mean +/- SD age of the patients was 49.1 +/- 13.6 years [range: 12-84 years]. We performed MSCT in 111 and DSA in 85 patients. the sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive and negative likelihood ratio [LR] of MSCT angiography, when compared with DSA as the gold standard, were 100%, 90%, 87.5%, 100%, 10 and 0, respectively. MSCT angiography seems to be an accurate and non-invasive imaging modality in the diagnosis of intracranial aneurysms

Hepatic doppler ultrasound in assessment of the severity of esophageal varices in cirrhotic patients

Endoscopy is the gold-standard technique for the assessment of acutely hemorrhagic esophageal varices in patients with hepatic cirrhosis. The objective of this study is to determine the value of different hepatic vasculature Doppler ultrasonography and their flow characteristics for non-invasive assessment of esophageal varices. Fifty-five [31 male, 24 female] consecutive patients with a mean +/- SD age of 55 +/- 16 [range: 20-88] years, with biopsy-proven hepatic cirrhosis were prospectively studied using Doppler ultrasonography. All of these patients were also examined endoscopically and by echocardiography. None of patients had clinical or echocardiographic signs of right heart failure, tricuspid valve regurgitation or previous history of therapeutic interventions on varices. An ordinal logistic regression [OLR] model was used for determining the adjusted associations between sizes of esophageal varices and hepatic hemodynamic determinants. There was a significant correlation between the size of esophageal varices and maximum portal vein velocity, which was lower in patients with varices [p= 0.04]. Other parameters though not statistically significant, were of clinical importance. Those included portal vein mean velocity [p = 0.08], hepatic artery volume flow [p = 0.06] and hepatic venous waveform pattern [p = 0.15]. OLR model did not show any significant adjusted associations between these parameters and the size of esophageal varices. The maximum portal vein velocity and to a lesser extent, hepatic artery volume flow were superior to Doppler ultrasonographic spectral waveform pattern of hepatic vein in differentiating patients with esophageal varices from those with no varices. None of hepatic vasculature Doppler measurements had a significant role in predicting the size of esophageal varices, nonetheless

evaluation of the performance assessment of APACHE III scoring system in patients admitted in the ICUs of TUMS with Sina designed APACHE scoring model

Performance assessment of intensive care units may not be possible unless there are objective criteria. This performance eventually determines patients' outcome and is the most reliable outcome measure for intensive care in hospital mortality. Scoring systems have been proposed for individual patient outcome prediction, for evaluating the performance of ICUs and for therapeutic trials. Despite a reasonable accuracy of scoring systems for predicting mortality, probability of defined ICU populations in developed countries, the healthcare delivery systems and patient characteristics in developing countries might influence the correlation between a given scoring instrument and the probability of death. Accordingly, intensive care physicians in developing countries should verify the accuracy of the available severity scoring systems in their specific settings by an objective validation process. This study tries to evaluate validity of APACHE III model in patients admitted to ICUs of Tehran University Medical Sciences intensive care units based on assessing calibration and discrimination. In the study, 1312 patients were analyzed. The mean age was 48.7 and median of length of stay at ICU and hospital was 4 and 9 days, respectively. Mean APACHE III score was 60 at first day of admission. Customized APACHE III [APACHE IIIc] model had poor calibration [P<0.0001], but good discrimination [area under ROC curve =0.88].In comparison, Sina-designed APACHE III [APACHE Ills] model had appropriate calibration [P value =0.4] and good discrimination [area under ROC curve =0.87]. Although APACHE Ills model sensitivity was about 70%, acceptable specificity [86.1%] plus corrected classification percent as%79, it is being introduced as an acceptable model in intensive care units of Tehran University of Medical Sciences; however extended use of this model needs more comprehensive studies