Prevalence of Structural Heart Diseases Detected by Handheld Echocardiographic Device in School-Age Children in Iran: The SHED LIGHT Study.

Background: Structural heart disease (SHD) has great impacts on healthcare systems, creating further public health concerns. Proper data are scant regarding the magnitude of the affected population by SHD. Objectives: This study aimed to determine the prevalence of SHD among children and adolescents in an Iranian population. Methods: In this population-based study, a multistage cluster-random sampling was used to choose schools from the Tehran urban area. All students were examined using a handheld Vscan device by echocardiographer, and the results were concurrently supervised and interpreted by cardiologists. All the major findings were reevaluated in hospital clinics. Results: Of 15,130 students (6-18 years, 52.2% boys) who were examined, the prevalence of individuals with congenital heart disease (CHD) and cardiomyopathy was 152 (10.046 per 1,000 persons) and 9 (0.595 per 1,000 persons), respectively. The prevalence of definite and borderline rheumatic heart disease (RHD) was 30 (2 per 1,000 persons) and 113 (7.5 per 1,000 persons), correspondingly. Non-rheumatic valvular heart disease (VHD) was also detected in 465 (30.7 per 1,000 persons) students. Of all the pathologies, only 39 (25.6%) cases with CHD and 1 (0.007%) cases with RHD had already been diagnosed. Parental consanguinity was the strongest predictor of CHD and SHD (odds ratio [OR]: 1.907, 95% CI, 1.358 to 2.680; P < 0.001 and OR, 1.855, 95% CI, 1.334 to 2.579; P < 0.001, respectively). The female sex (OR, 1.262, 95% CI, 1.013 to 1.573; P = 0.038) and fathers' low literacy (OR, 1.872, 95% CI, 1.068 to 3.281; P = 0.029) were the strongest predictors of non-rheumatic VHD and RHD, correspondingly. Conclusions: The implementation of echocardiographic examinations for detecting SHD among young population is feasible which detected SHD prevalence in our population comparable to previous reports. Further studies are required to delineate its economic aspects for community-based screening.

A rare cause of complete heart block in an adult: Primary cardiac lymphoma.

Primary cardiac lymphoma (PCL) is a rare primary cardiac neoplasm with a relatively poor prognosis despite confinement to the heart and/or pericardium. We report a 54-year-old man who had presented with complete heart block for which he had undergone permanent pacemaker implantation, and six months later he was referred to us for evaluation of progressive exertional dyspnea. Multislice spiral computed tomography angiography of the heart and major vasculature showed infiltrative tumoral lesion that has involved interatrial septum, right atrium, left atrium, and left ventricle with invasion into the pulmonary artery. Tissue samples were taken using uniportal video-assisted thoracoscopic surgery, and the histologic examination revealed diffuse large B-cell lymphoma. Chemoimmunotherapy was effective in inducing tumor regression and the patient was still in remission during the next six months after treatment.

Surgical septal myectomy for hypertrophic cardiomyopathy. The Iranian experience.

INTRODUCTION: Hypertrophic obstructive cardiomyopathy (HOCM) is a hereditary heart muscle disorder characterized by significant myocardial hypertrophy. we assessed perioperative and long-term follow-up data of Iranian HOCM patients who underwent SM in 2 pioneering centers. METHODS: Clinical data of patients with HOCM septal myectomy are collected. Thirty-day outcome and long-term follow-up data for recurrence of gradient and mortality are reported. RESULTS: Ninety-six patients in two different centers enrolled in the study. Most patients of 52 patients in center 1 were male (34/52 [65.3%]).and the mean age was of 36.7 ± 19 years. Syncope before admission was reported in 5.7%, the mean left ventricular ejection fraction on admission was 53 ± 8%, the mean left ventricular outflow tract gradient was 66.3 ± 20.4 mm Hg, and the mean preoperativeseptal thickness was 25.4 ± 6.7 mm. A redo SM was performed in 3 patients (5.8%), mitral valve repair in 5 patients (9.6%), and atrioventricular repair in 5 patients (9.6%). A residual systolic anterior motion was detected in 4 patients (7.7%), the mean postoperative septal thickness was 19 ± 6 mm (25.1% septal thickness reduction), and in-hospital mortality was 5.8% (n = 3). A longer-term follow-up showed death in 3 patients (5.8%) and late recurrent left ventricular outflow tract obstruction in 1 patient. CONCLUSIONS: Transaortic myectomy is an effective surgery with acceptable early and late mortality rates. Improvements in functional status are seen in almost all patients. Appropriate SM is crucial to a good clinical outcome. Long-term survival is excellent and cardiac sudden death is extremely rare after a good surgical treatment.

Effects of intravenous and transdermal photobiomodulation on the postoperative complications of coronary artery bypass grafting surgery: a randomized, controlled clinical trial.

Although coronary artery bypass graft (CABG) surgery is one of the most worldwide commonly performed cardiac surgeries to enhance myocardial perfusion in high-grade myocardial occlusion, it remains a high-risk procedure. Photobiomodulation (PBM) is one of the methods which have been shown to have positive effects on the healing process after CABG and postoperative complications. The aim of this study was to evaluate the efficacy of PBM in patients who underwent a coronary artery bypass graft (CABG). Ths study was conducted with 192 volunteers who electively submitted to CABG. The volunteers were randomly allocated into two groups: laser-treated (transdermal: 980 nm, 200 mW, continuous, average energy fluency of 6 J/cm2 and intravenous: 405 nm, 1.5 mW, continuous for 30 min) and standard treatment and control group (standard treatment only). Intravenous laser was illuminated the day before the surgery, immediately after transferring the patient to CCU post-operation and IV laser in addition to transdermal laser was applied every day after surgery for 6 days. A total of 170 out of 192 participants completed the study, 82 (48.2%) in the PBM group and 88 (51.8%) in the control group. Level of LDH and CPK was significantly lower in the PBM group (P < 0.05) in the 4th day postoperatively. The PBM group also showed significantly lower post-surgery complications, including pericardial effusion, ejection fraction, pathologic ST changes, pathologic Q, rehospitalization, heart failure, and mediastinitis (P < 0.05). Likewise, the VAS pain score after surgery was significantly lower in patients in the laser group (P < 0.05). PBM seems a promising, safe, cost-benefit therapeutic modality to reduce postoperative complications of CABG. Trial registration number: IRCT2016052926069N4 .

Postoperative Atrial Fibrillation Following Cardiac Surgery: From Pathogenesis to Potential Therapies.

Postoperative atrial fibrillation (POAF) is a major complication after cardiac surgery which can lead to high rates of morbidity and mortality, an enhanced length of hospital stay, and an increased cost of care. POAF is postulated to be a multifactorial phenomenon; however, some major pathogeneses have been proposed, including inflammatory pathways, oxidative stress, and autonomic dysfunction. Genetic studies also showed that inflammatory pathways, beta-1 adrenoreceptor variants, G protein-coupled receptor kinase 5 gene variants, and non-coding single-nucleotide polymorphisms in the 4q25 chromosomal locus are involved in this phenomenon. Moreover, several predisposing factors lead to the development of POAF, consisting of pre-, intra-, and postoperative contributors. The main predisposing factors comprise age, prior history of major cardiovascular risk factors, and ischemia-reperfusion injury during surgery. The management of POAF is based on the usual therapies used for non-surgical AF, including medications for either rate control or rhythm control in hemodynamically unstable patients. The perioperative administration of ß-blockers and some antiarrhythmic agents has been recommended in major international guidelines. In addition, upstream therapies consisting of colchicine, magnesium, statins, and antioxidants have attenuated the incidence of POAF; however, some uncomfortable side effects developed in large randomized trials. The use of anticoagulation has also resulted in less mortality in patients with POAF at higher risk of thromboembolic events. Despite these recommendations, the actual regimen for the prevention of POAF remains controversial. In this review, we highlight the pathogenesis, predisposing factors, and potential therapeutic options for the management of patients at risk for or with POAF following cardiac surgery.

A comprehensive multimodality heart motion prediction algorithm for robotic-assisted beating heart surgery.

BACKGROUND: An essential requirement for performing robotic-assisted surgery on a freely beating heart is a prediction algorithm that can estimate the future heart trajectory. METHOD: Heart motion, respiratory volume (RV) and electrocardiogram (ECG) signal were measured from two dogs during thoracotomy surgery. A comprehensive multimodality prediction algorithm was developed based on the multivariate autoregressive model to incorporate the heart trajectory and cardiorespiratory data with multiple inherent measurement rates explicitly. RESULTS: Experimental results indicated strong relationships between the dominant frequencies of heart motion with RV and ECG. The prediction algorithm revealed a high steady state accuracy, with the root mean square (RMS) errors in the range of 82 to 162 µm for a 300-second interval, less than half of that of the best competitor. CONCLUSION: The proposed multimodality prediction algorithm is promising for practical use in robotic assisted beating heart surgery, considering its capability of providing highly accurate predictions in long horizons.

A Hybrid Algorithm for Prediction of Varying Heart Rate Motion in Computer-Assisted Beating Heart Surgery.

An essential requirement for performing robotic assisted surgery on a freely beating heart is a prediction algorithm which can estimate the future trajectory of the heart in the varying heart rate (HR) conditions of real surgery with a high accuracy. In this study, a hybrid amplitude modulation- (AM) and autoregressive- (AR) based algorithm was developed to enable estimating the global and local oscillations of the beating heart, raised from its major and minor physiological activities. The AM model was equipped with an estimator of the heartbeat frequency to compensate for the HR variations. The RMS of the prediction errors of the hybrid algorithm was in the range of 165-361 µm for the varying HR motion, 21% less than that of the single AM model. With the capability of providing highly accurate predictions in a wide range of HR variation, the hybrid model is promising for practical use in robotic assisted beating heart surgery.

Feasibility of infrared tracking of beating heart motion for robotic assisted beating heart surgery.

BACKGROUND: Accurate tracking of the heart surface motion is a major requirement for robot assisted beating heart surgery. METHOD: The feasibility of a stereo infrared tracking system for measuring the free beating heart motion was investigated by experiments on a heart motion simulator, as well as model surgery on a dog. RESULTS: Simulator experiments revealed a high tracking accuracy (81 µm root mean square error) when the capturing times were synchronized and the tracker pointed at the target from a 100 cm distance. The animal experiment revealed the applicability of the infrared tracker with passive markers in practical heart surgery conditions. CONCLUSION: With the current technology, infrared tracking with passive markers might be the optimal solution for accurate, fast, and reliable tracking of heart motion during robot assisted beating heart surgery.

Different Presentation of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in Adults: Case Reports.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac malformation. We report three cases of ALCAPA who survived to adulthood. The first case was a 51-year-old woman who complained of typical chest pain that was diagnosed with ALCAPA using cardiac catheterization and coronary computed tomographic angiography (CTA). The second case was a 30-year-old woman with a history of surgery for atrial septal defect at 10 years old who presented with progressive exertional dyspnea. Cardiac catheterization confirmed the diagnosis of ALCAPA. The third case was a 19-year-old man who was brought to our clinic due to aborted sudden cardiac death on the previous day. Cardiac catheterization and coronary CTA confirmed the diagnosis. They underwent the closure of orifice of the anomalous left coronary artery and grafting the left anterior descending artery concomitantly with mitral valve repair. All patients were followed up during a mean of 8.7 months and they were asymptomatic.

Mid-term outcomes of surgical repair for anomalous origin of the left coronary artery from the pulmonary artery: In infants, children and adults.

BACKGROUND: Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital malformation. We sought to evaluate in-hospital and mid-term outcomes of patients with a diagnosis of ALCAPA who underwent surgical repair. OBJECTIVES: The objective of this study is to evaluate the mid-term outcomes of surgical repair of ALCAPA at our center and to analyze the surgical techniques used. MATERIALS AND METHODS: In a retrospective study, we analyzed early and mid-term clinical and echocardiographic data to determine the outcomes of patients who underwent surgical repair of ALCAPA in our institution between 2005 and 2015. RESULTS: Twenty-one patients underwent surgical repair for ALCAPA using aortic reimplantation (n = 10, 47.6%), ostial closure (n = 8, 38.1%), or ligation (n = 3, 14.3%). The median age of patients was 24 months (range 22 days to 51 years). There were 2 (9.5%) in-hospital mortalities in infants undergoing the reimplantation technique. All patients were followed up for a median of 21 months (range 1-60 months). No patients required reoperation, and there was no mortality from discharge to mid-term follow-up. Severe early postoperative mitral regurgitation (MR) was associated with composite end-point, defined as a combination of mortality after surgery, moderate to severe MR, and moderate to severe left ventricular dysfunction at late follow-up (P = 0.019) while mitral valve repair was not (P = 0.469). CONCLUSION: The surgical management of ALCAPA can be associated with good in-hospital and mid-term outcomes regardless of the age, at which the patient has been operated.

Feto-maternal outcomes of urgent open-heart surgery during pregnancy.

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery during pregnancy is rarely required and potentially increases feto-maternal mortality. The study aim was to evaluate pregnancy outcomes in females who underwent open-heart surgery with cardiopulmonary bypass (CPB) during pregnancy. METHODS: Between 1999 and 2014, a total of 16 pregnant women (mean age 27 ± 7 years; mean gestational age 13 ± 7.7 weeks) underwent urgent cardiac surgery using CPB. The preoperative diagnosis included prosthetic valve dysfunction in 12 women (five aortic, seven mitral), native valve endocarditis and critical aortic stenosis each in one woman, and intracardiac masses in two women. Eleven patients were in the first trimester, three in the second trimester, and two in the third trimester. A retrospective analysis was conducted that included maternal variables of age, gestational age, cardiac diagnosis, prior operations, surgical details, maternal morbidity and mortality and type of delivery, while fetal variables included incidence of low birth weight, prematurity, and fetal malformation. Patients were allocated to two groups: Group A (n = 9) included pregnant women with living neonates, while group B (n = 7) included pregnant women with an aborted fetus or dead neonate. All data were compared between the groups. RESULTS: There was no in-hospital maternal mortality. There were no significant differences between the two groups regarding age, gestational age, previous cardiac operation, type of surgery, duration of operation, perfusion pressure and core temperature during CPB. The CPB time was longer in group B (110.3 ± 57.1 min) than in group A (62 ± 15.7 min) (p = 0.028), as was the aortic cross-clamp time (54.3 ± 27.2 min and 38.7 ± 9.3 min in groups A and B, respectively) (p = 0.014). Group B patients received higher doses of inotropes perioperatively. No congenital abnormalities were identified in any of the living neonates. CONCLUSION: The durations of CPB and aortic cross-clamping may not affect maternal outcome, but shorter CPB and aortic cross-clamp times led to better fetal outcomes. Increasing the perioperative dosage of inotropes may lead to a reduced fetal survival.

Rotational thromboelastometry in prediction of bleeding after cardiac surgery.

BACKGROUND: Reexploration and its associated complications significantly affect hospital mortality and morbidity. Therefore, to prevent postoperative bleeding and its related complications, using an appropriate modality is essential during cardiac surgery. METHODS: Four hundred patients (296 males and 104 females, mean age 60.8 ± 9 years) scheduled for first-time coronary artery bypass graft surgery were prospectively enrolled. Blood samples were obtained for ROTEM testing before surgery and 30 min after heparin reversal. The patients were divided into 2 groups: group 1 was patients with no abnormal postoperative bleeding and group 2 was patients who required reexploration for abnormal postoperative bleeding. Group 2 patients were divided into 2 subgroups: 2a was patients with surgical bleeding and group 2b was patients with nonsurgical bleeding. Variables were compared between groups. RESULTS: Among the 400 patients, 42 were reexplored. Hospital stay was significantly longer and hospital deaths more frequent in group 2 patients (p < 0.001 and p = 0.010, respectively). Ten (2.8%) patients had abnormal preoperative results of ROTEM in group 1 compared to 14 (33.3%) in group 2 (p < 0.001). After surgery, the number of patients with abnormal ROTEM results was significantly different between the 2 groups: 6 (1.7%) in group 1 vs. 14 (33.3%) in group 2 (p < 0.001). Four (12.5%) patients in group 2a had abnormal preoperative ROTEM results compared to 10 (100%) in group 2a (p < 0.001). CONCLUSION: Measuring coagulation factors by ROTEM both before surgery and after heparin reversal can identify patients at increased risk of postoperative bleeding.

Long-Term Outcome of Mechanical Pulmonary Valve Replacement in 121 Patients with Congenital Heart Disease.

BACKGROUND: A tissue valve is the prosthesis of choice in the majority of children and adults requiring pulmonary valve replacement (PVR). Mechanical valves, on the other hand, are more durable but require anticoagulation therapy and carry the elevated risk of thrombosis. The aim of this study was to investigate the long-term outcomes of mechanical prosthetic valves in a single referral tertiary center. Patients and METHODS: Recorded data of 121 patients who underwent mechanical PVR between April 2003 and April 2013 at our center were reviewed, retrospectively. Eighty-four patients (69.4%) were male and their mean age was 23.12 ± 7.86 years. Tetralogy of Fallot was the most common diagnosis (n = 109). Complete follow-up was performed for all patients (mean 7.02 ± 1.90 years). RESULTS: Nobody died and no significant bleeding event was detected during follow-up. Mechanical valve malfunction happened in 10 patients (8.3%) while in 1 of them malfunction happened because of pannus formation and in the remaining 9 because of thrombosis. Just one of the thrombotic events could not be treated with streptokinase and required reoperation. Freedom from reoperation rates were 100, 99, and 98% at 1, 5, and 10 years, respectively; freedom from valve thrombosis event rates were 100, 93, and 91% at 1, 5, and 10 years, respectively; and freedom from bleeding event rates was 98% at 1, 5, and 10 years. CONCLUSION: Mechanical prosthetic valves demonstrated excellent durability and a low risk of valve thrombosis at the pulmonary position when patients are adequately anticoagulated.

Two new mathematical models for prediction of early mortality risk in coronary artery bypass graft surgery.

OBJECTIVES: The aim of this study was to develop new models for prediction of short-term mortality risk in on-pump coronary artery bypass grafting (CABG) surgery using decision tree (DT) methods. METHODS: Between September 2005 and April 2006, 948 consecutive patients underwent CABG surgery at Rajaie Heart Center. Potential risk factors were reviewed and univariate and multivariate analysis for short-term mortality were performed. The whole dataset was divided into mutually exclusive subsets. An entropy error fuzzy decision tree (EEFDT) and an entropy error crisp decision tree (EECDT) were implemented using 650 (68.6%) patient data and tested with 298 (31.4%) patient data. Ten times hold-out cross validation was done and the area under the receiver operative characteristic curve (AUC) was reported as model performance. The results were compared with the logistic regression (LR) model and EuroSCORE. RESULTS: The overall short-term mortality rate was 3.8%, and was statistically higher in women than men (P<.001). The final EEFDT selected 19 variables and resulted in a tree with 39 nodes, 20 conditional rules, and AUC of 0.90±0.008. The final EECDT selected 15 variables and resulted in a tree with 35 nodes, 18 conditional rules, and AUC of 0.86±0.008. The LR model selected 10 variables and resulted in an AUC of 0.78±0.008; the AUC for EuroSCORE was 0.77±0.003. There were no differences in the discriminatory power of EEFDT and EECDT (P=.066) and their performance was superior to LR and EuroSCORE. CONCLUSIONS: EEFDT, EECDT, LR, and EuroSCORE had clinical acceptance but the performance and accuracy of the DTs were superior to the other models.

Long-term results of aortic valve replacement with posterior root enlargement.

BACKGROUND: Posterior root enlargement provides the implantation of suitable-sized prosthetic valves in patients with a small aortic root. The aim of this study was to evaluate the long-term results of posterior root enlargement in patients undergoing aortic valve replacement. METHODS: Between 1997 and 2011, 103 patients with a small aortic annulus (indexed effective orifice area < 0.75 cm(-2) · m(-2)) underwent aortic valve replacement with posterior aortic root enlargement. Forty-six (44%) patients were male. The mean age was 28.62 ± 18.56 years. Survivors were followed up for a mean of 45.6 ± 32.4 months. RESULTS: Early mortality was 9.6%. The most common cause of early mortality was low cardiac output syndrome (6 patients). There were 2 (1.9%) late deaths due to cerebrovascular events. During the follow-up period, mild paravalvular leakage occurred in only one (1%) patient, and one suffered a malfunction of the prosthesis. A significant reduction was seen in the peak pressure gradients across the replaced aortic valves (p < 0.001). Moreover, a significant increase was noted in left ventricular ejection fraction (p = 0.001). CONCLUSIONS: Aortic root enlargement using the Manouguian technique can be applied with acceptable safety. It effectively decreases postoperative gradients and increases left ventricular ejection fraction. Short- and long-term mortality and morbidity rates are satisfactory.

Modified aortic root replacement technique in destructive ventricular-aortic discontinuity.

We describe a simple technique for aortic root replacement in destructive prosthetic aortic valve endocarditis wherein the fragile aortic annulus tissue is not suitable for suture placement. Therefore, we first reconstructed the intervalvular part with a nontreated pericardial patch and then implanted the aortic composite graft on the aortic root through the roof of the left atrium and reconstructed the defect thus made with another pericardial patch. No complication was seen at 6-month follow up.

A rare case of right-sided heart failure after bentall procedure.

Pseudoaneurysms of the ascending aorta, which are rare and life-threatening complications in cardiovascular surgeries, can be caused by the Bentall procedure. We describe a 44-year-old woman, who had a medical history of acute aortic dissection (Type A) and the Bentall procedure and was admitted because of exertional dyspnea, edema of the lower extremities, ascites, and holosystolic murmur in the left lower sternal border. Preoperative echocardiography revealed a pseudoaneurysm of the ascending aorta and fistulization of the pseudoaneurysm to the right atrium. Multi-slice computed tomographic scan also showed a large pseudoaneurysm of the ascending aorta around the tube graft. The patient underwent surgery, during which the pseudoaneurysm was resected, the ostium of the right coronary artery was reimplanted, and the orifice of the right atrial fistula was sutured. Intraoperative transesophageal echocardiography revealed the perfect result of the surgery. The patient was discharged uneventfully.

Premeasured neochordae loop maker: a new technology in mitral valve repair.

The exact length of neochordae loops plays the major role in the success of mitral valve repair. The Neochordae Loop Maker is a novel device that models the left ventricular structure in an individual patient. Preoperative transthoracic echocardiography is used to identify the geometry of each papillary muscle and set up the device for the patient. All required neochordae loops are made in the operating room before initiating the cardiopulmonary bypass. In the calibration phase, seven consecutive patients who were candidates for mitral valve replacement underwent transthoracic echocardiography. The device was set up for each patient, and the length of their normal chordae and their respective neochordae was compared by the Bland-Altman analysis. From seven excised mitral valves, 21 chordae were considered normal (gold standard). The length of these gold standards (1.92 ± 0.67 cm) and their respective neochordae (1.93 ± 0.69 cm) showed agreement by the Bland-Altman analysis. The proposed technology showed satisfactory preliminary results in creating the premeasured neochorda loops inasmuch as it reduced the complexity of minimally invasive surgeries.