Ruptured sinus of valsalva aneurysm accompanied by aortic and tricuspid valve endocarditis: a case report

A ruptured sinus of Valsalva aneurysm rarely accompanies the aortic and tricuspid valve endocarditis. A 36-year-old woman presented with low-threshold dyspnea on exertion and fever. Transthoracic and transesophageal echocardiography showed a ruptured noncoronary sinus of Valsalva aneurysm with large vegetations on the tricuspid and aortic valves, resulting in moderately severe tricuspid regurgitation and severe aortic regurgitation. Blood culture was negative. The patient was initially treated with antibiotics and then subjected to the surgical repair of the sinus of Valsalva aneurysm and the tricuspid and aortic valve replacement. The patient's postoperative period was uneventful, and she was discharged healthy

Percutaneous mitral valve repair with the edge-to-edge technique: case series of first Iranian experience

Mitral regurgitation [MR] is a common valvular lesion in the general population with considerable impact on mortality and morbidity. The MitraClip System [Abbot Laboratories, Abbot Park, IL, USA] is a novel percutaneous approach for treating MR which involves mechanical edge-to-edge coaptation of the mitral leaflets. We present our initial experience with the MitraClip System in 5 patients. In our series, the cause of MR was both degenerative and functional. Two patients received two MitraClips due to unsatisfactory results after the implantation of the first clip. Acute procedural success was seen in 4 patients. Blood transfusion was required for 2 patients. All the patients, except one, reported improvement in functional status during a 2-month follow-up period. Our initial experience with MitraClip implantation indicates that the technique seems feasible and promising with acceptable results and that it could be offered to a broader group of patients in the near future

Endovascular repair of supra-celiac and abdominal aortic pseudo aneurysms concomitant with a right atrial mass in a patient with behcet's disease: a case report

Behcet's disease is a rare immune mediated systemic vasculitis which besides it's more frequent involvement of eyes and skin, sometimes present with aortic pseudo aneurysm and more rarely cardiac inflammatory masses. A 51-year-old patient with Behcet's Disease presented with two symptomatic aortic pseudoaneurysms concomitant with a right atrial mass. Computed tomography [CT] revealed one supra-celiac and another infrarenal aortic pseudoaneurysms. Echocardiography showed a large mobile mass in the right atrium. Both pseudoaneurysms were successfully excluded simultaneously via endovascular approach with Zenith stent-grafts, and the atrial mass was surgically removed 10 days later. Post-implant CT showed successful exclusion of both pseudo-aneurysms, patency of all relevant arteries, and patient is now asymptomatic and has returned to normal lifestyle. Multiple pseudoaneurysms concomitant with a right atrial mass can be an initial manifestation of Behcet's disease. Endovascular repair can be a good treatment option for the pseudoaneurysms

Endovascular treatment of isolated bilateral internal iliac artery aneurysms with a branched endograft: a case report

Isolated bilateral internal iliac artery [IIA] aneurysm is a rare and potentially lethal disease. Endovascular repair of this disorder is a matter of debate. A symptomatic 68-year-old male presented with severe pelvic pains. Computed tomography revealed a leaking 46-mm aneurysm in the right IIA, a 27-mm aneurysm in the left IIA, and ectatic changes at a diameter of 31 mm in the right common iliac artery [CIA]. Due to lower rates of morbidity and mortality, an endovascular approach was chosen instead of open surgical repair. However, due to anatomical constraints, an endograft had to be implanted in a healthy aorta in order to support an iliac branch endograft in the left CIA. Subsequently, following coil embolization of the left IIA, an iliac stent graft was extended to the right external iliac artery [EIA]. Two-year follow-up CT imaging showed complete exclusion of all the aneurysms and patency of the pelvic visceral arteries. The patient is currently asymptomatic. Endovascular repair of bilateral isolated IIAs can be a feasible treatment option. However, due to the limited availability of sizes in iliac branch devices currently on the market, a main body device is sometimes required to be deployed in a healthy aorta for additional endograft support

Impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on mortality of coronary artery bypass grafting

There is controversy over the potential benefits/harms of the usage of angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs] as regards the postoperative mortality of coronary artery bypass grafting [CABG]. This study investigates the correlation between the in-hospital mortality of CABG and the preoperative administration of ACEI/ARB. Out of 10055 consecutive patients with isolated CABG from 2006 to 2009, 4664 [46.38%] patients received preoperative ACEI/ARB. Data were gathered from the Cardiac Surgery Registry of Tehran Heart Center. In-hospital mortality was defined as death within the same admission for surgery. Adjusted for confounders, multivariable logistic regression models were used to evaluate the impact of preoperative ACEI/ARB therapy on in-hospital death. The mean age of the patients was 60.04 +/- 9.51 years and 7364 [73.23%] were male. Eighty-seven [0.86%] patients expired within 30 days. Multivariate analysis revealed that the administration of ACEI/ARB significantly protected against in-hospital deaths in as much as there were 33 [0.70%] vs. 54 [1.0%] deaths in the ACEI/ARB positive and negative groups, respectively [OR: 0.628; p value = 0.09]. Patients without ACEI/ARB were more likely to have a higher global ejection fraction. Preoperative ACEI usage in patients undergoing CABG can be associated with decreased in-hospital mortality. Large-scale randomized clinical trials are suggested

Knowledge management in cardiac surgery: the second Tehran heart center adult cardiac surgery database report

The Adult Cardiac Surgery Databank [ACSD] of Tehran Heart Center was established in 2002 with a view to providing clinical prediction rules for outcomes of cardiac procedures, developing risk score systems, and devising clinical guidelines. This is a general analysis of the collected data. All the patients referred to Tehran Heart Center for any kind of heart surgery between 2002 and 2008 were included, and their demographic, medical, clinical, operative, and postoperative data were gathered. This report presents general information as well as in-hospital mortality rates regarding all the cardiac procedures performed in the above time period. There were 24959 procedures performed: 19663 [78.8%] isolated coronary artery bypass grafting surgeries [CABGs]; 1492 [6.0%] isolated valve surgeries; 1437 [5.8%] CABGs concomitant with other procedures; 832 [3.3%] CABGs combined with valve surgeries; 722 [2.9%] valve surgeries concomitant with other procedures; 545 [2.2%] surgeries other than CABG or valve surgery; and 267 [1.1%] CABGs concomitant with valve and other types of surgery. The overall mortality was 205 [1.04%], with the lowest mortality rate [0.47%] in the isolated CABGs and the highest [4.49%] in the CABGs concomitant with valve surgeries and other types of surgery. Meanwhile, the overall mortality rate was higher in the female patients than in the males [1.90% vs. 0.74%, respectively]. Isolated CABG was the most prevalent procedure at our center with the lowest mortality rate. However, the overall mortality was more prevalent in our female patients. This database can serve as a platform for the participation of the other countries in the region in the creation of a regional ACSD.

Post-traumatic chordae rupture of tricuspid valve

Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports of pain to florid shock. Traumatic tricuspid valve regurgitation is a rare cardiovascular complication of blunt chest trauma. Tricuspid valve regurgitation is usually begotten by disorders that cause the right ventricle to enlarge. Diagnosis is made by physical examination findings and is confirmed by echocardiography. We report two cases of severe tricuspid regurgitation secondary to the rupture of the chordae tendineae of the anterior leaflet following non-penetrating chest trauma. Both patients had uneventful postoperative courses

Determinant factors of renal failure after coronary artery bypass grafting with on-pump technique

The aim of the present study was to investigate the determinant factors of acute renal failure [ARF] after isolated on-pump coronary artery bypass grafting [CABG]. This was a retrospective study of 13, 315 adult patients who underwent isolated CABG with cardiopulmonary bypass [CPB] in Tehran Heart Center from May 2002 to May 2007. The exclusion criteria were age <18, concomitant cardiac and/or noncardiac surgical operations, history of renal failure before surgery, and chronic renal failure requiring dialysis. Preoperative and operative variables were measured, and a multivariate logistic regression model was constructed to identify the independent risk factors for developing renal failure after on-pump CABG. Of the 13,315 patients, 3,347 [25.4%] and 90,883 [74.6%] were females and males, respectively, with a mean age of 58.63 +/- 9.48 years. ARF was detected in 85 [0.6%] of the patients with isolated on-pump CABG. The mean age of the patients was 58.63 +/- 9.48 years, and 25.5% of them were female. The multivariate logistic regression analysis identified age [OR = 1.035; p = 0.002], female gender [OR = 1.622; p = 0.037], history of peripheral vascular disease [PVD] [OR = 2.579; p = 0.042], diabetes mellitus [OR = 1.918; p < 0.001], emergent and urgent surgery [OR = 1.744 and OR = 7.901, respectively; p = 0.003], CPB time >70 min [OR = 1.944; p = 0.007], and intra-aortic balloon pump [IABP] insertion [OR = 10.181; p < 0.001] as the independent risk factors for ARF. The data showed that age, female gender, positive history of diabetes and PVD, urgent and emergent surgery, CPB time >70 min, and need for IABP were the independent determinant factors of ARF after on-pump CABG

Impact of diabetes mellitus on peripheral vascular disease concomitant with coronary artery disease

The aim of this study was to evaluate the impact of diabetes mellitus [DM] on peripheral vascular disease [PVD] in patients with coronary artery disease [CAD]. A total of 13702 consecutive patients who underwent coronary artery bypass grafting [CABG] at Tehran Heart Center between January 2002 and March 2007 were included in this study. The demographic data, PVD, and outcome of these patients were reviewed. CABG patients before surgery were detected for PVD [stenosis >/= 70% in the abdominal aorta; renal, carotid, and iliac arteries; or any other peripheral vascular system] with physical examination and past medical history. The suspected cases of PVD were, thereafter, confirmed via Doppler sonography or invasive angiography. This study recruited 4344 diabetic patients [mean age 59.30 +/- 8.7 years] and 9358 non-diabetic patients [mean age 58.42 +/- 9.9 years]. The diabetics were significantly older and had a higher incidence of PVD [2.7% vs. 1.8%], female gender, hypertension, renal failure, smoking, and dyslipidemia than the non-diabetics [P < 0.05]. There was no significant difference between the two groups with regard to family history and left main disease. Also, the mean ejection fraction [EF] was 48.85% +/- 10.4 and 49.35% +/- 10. In the patients with and without DM, respectively; and the difference was significant [P = 0.008]. The in-hospital mortality rate [mortality over a 30-day post-operative period] was 1.8% in the diabetics and 0.7% in the non-diabetics [P < 0.001]. In the multivariate analysis, PVD, left main disease, age, female gender, and EF were significant in the development of mortality amongst the diabetic patients with a respective odds ratio of 4.17, 5.54, 1.03, 2.86, and 0.95 [P

Surgical treatment of atrial fibrillation

Atrial fibrillation is the most prevalent permanent arrhythmia. It may be associated with other cardiac pathologies which need surgical treatment. Various types of surgery including the traditional cut-sew operations and operations using different energy sources are currently in use. In comparison with medical treatment, surgery is safe, effective, and has reliable results.

Coronary artery bypass surgery versus medical treatment in patients with low ejection fraction and coronary artery disease

We compared the outcomes in patients with a low ejection fraction [EF] and multivessel coronary artery disease [CAD] who either underwent coronary artery bypass grafting [CABG] or received medical treatment [MT] after a viability study via dobutamine stress echocardiography [DSE]. We considered patients with CAD and left ventricular ejection fraction [LVEF] 25% [100% vs. 40%, p < 0.05]. The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium

Coronary artery bypass grafting combined with total occlusion of internal carotid artery

The presence of significant carotid stenosis in coronary artery bypass grafting [CABG] patients increases the risk of either transient ischemic attack or stroke. However, there is a dearth of data on the risk for patients with unilateral total occlusion of the carotid artery. We herein report our results of cardiac surgery in patients with unilateral total occlusion of the carotid artery. We examined 10,000 patients who underwent carotid artery duplex scanning before CABG or other cardiac procedures between January 2001 and September 2006 at Tehran Heart Center. The occlusions were detected via carotid Doppler screening and were confirmed through conventional or MR angiography. Among these patients, 15 [0.15%] patients had unilateral total occlusion of the internal carotid artery, and all of them underwent elective cardiac surgery. During cardiopulmonary bypass, the mean arterial pressure was maintained at above 60 mmHg with vasopressure drugs and increasing flow pump. There were 4 patients with left and 11 patients with right carotid occlusions. Four patients had a history of cerebrovascular accident. The mean cross-clamp time [min] and perfusion time [min] was 50.7 +/- 17.3 and 94.2 +/- 26.7, respectively. The mean graft number was 4.1 +/- 0.9. One of these patients expired intraoperatively because of low cardiac output. In one [6.66%] patient, postoperative cerebrovascular accident occurred on the contralateral side of the totally occluded region. All the patients recovered uneventfully. Our results suggest that CABG can be performed in patients with unilateral total occlusion of the internal carotid artery without ipsilateral stroke using our strategies

Early outcome of coronary artery bypass grafting in patients with severe left ventricular dysfunction

Left ventricular dysfunction is one of the most powerful predictors of early and late outcomes in patients who undergo coronary artery bypass grafting [CABG]. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay [LOS] after CABG in patients with an ejection fraction [EF] of 30% or less. Seven hundred seven patients who underwent CABG with EF 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. The thirty-day mortality rate [2.3% vs. 0.8%, P<0.0001], the mean of LOS [P<0.0001], and the mean of the length of ICU stay [P<0.0001] were higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the mean of NYHA score [P=0.0081], prolonged ventilation [P=0.0051], and renal failure [P=0.0606] were related to the 30-day mortality rate. Also, the prolonged LOS in these patients was correlated with the female gender [P=0.0018] and atrial fibrillation [P=0.0164]. Although left ventricular dysfunction is itself an important strong risk factor in patients undergoing CABG, the early outcome of CABG in patients with left ventricular dysfunction is acceptable and the management of this factor will help to reduce the mortality and total length of stay in hospital

Pulmonary valve bacterial endocarditis in Tetralogy of Fallot

We report two cases of Tetralogy of Fallot with pulmonary valve bacterial endocarditis where one extended to the branch of pulmonary artery [PA]. This is a rare occurrence. Aggressive supportive care plus early and radical surgery can be life saving

Early outcome of coronary artery bypass grafting in patients less than 40 years old comparing with eldery patients

Age is one of the most important factors that have consistently emerged as the most potent predictors of mortality and morbidity after coronary artery bypass graft [CABG] surgery. However, early results of CABG in young patients in comparison with elderly ones have been different in previous surveys. The aim of this study was to compare shortterm mortality and morbidity in young versus older patients and evaluate the presence of risk factors and their influence on outcome in both groups. We conducted a retrospective database review of 13222 patients divided into two age groups: patients less than 40 years old [411 patients] and those older [12811 patients], who underwent CABG at Tehran Heart Center between January 2002 and January 2007. We also compared preoperative, operative, and postoperative characteristics between them and assessed the influence of the variables on the length of stay in hospital [LOS] in the two groups. Among postoperative complications, only atrial fibrillation [P<0.001] was more prevalent in the elderly group and other complications were similar. The thirty-day mortality rate was higher in the elderly group [1.1% vs. 0%, P=0.023]. Also, prolonged LOS [P<0.001] and ICU stay [P<0.001] were found more prevalent in the elderly group. Among the preoperative and postoperative variables, emergency surgery, diabetes mellitus, and previous myocardial infarction influenced the prolonged LOS in the young patients. Early mortality rate and prolonged length of stay in ICU and hospital were higher in the elderly than those in the young patients; however, other postoperative early complications were similar between the two groups

Free wall rupture and ventricular septal defect post acute anterior myocardial infarction

Myocardial free wall rupture is a catastrophic complication of acute myocardial infarction, and prognosis will depend on the prompt diagnosis by echocardiography, extension of infarct size, and prompt surgical treatment. Free wall rupture concomitant with ventricular septal defect [VSD] may be more complicated for management. A case of a 69-year-old man with myocardial free wall rupture and VSD following acute anterior myocardial infarction is presented

Main Pulmonary Artery Hydatidosis with Seconday Involvement of the Lungs: a Shepherd Boy's Story

Cardiac hydatid cyst [CHC] is a rare disease that was endemic in some regions especially in sheep-raising areas. The most commonly accepted theory for the routes of heart involvement in hydatid cyst was infestation by the hexacanthus embryo through coronary arteries.Here, we describe a case with the primitive cardiac hydatid cyst located around the pulmonary valve [PV] and main pulmonary artery [mPA] extended to right and left pulmonary arteries and metastasized to both lungs. Could it be possible for the embryo to adhere PV and mPA directly