Iranian Society of Cardiac Surgeons COVID-19 task force version II, restarting elective surgeries.

Given the nature of heart disease and the importance of continuing heart surgery during the pandemic and its aftermath and in order to provide adequate safety for the surgical team and achieve the desired result for patients, as well as the optimal use of ICU beds, the medical team, blood, blood products, and personal protective equipment, it is essential to change the usual approach during the pandemic. There are still a lot of evidences and experiences needed to produce the perfect protocol. Some centers may have a special program for their centers during this period of epidemics that can be respected and performed. Generally, in pandemic conditions, the use of non-surgical approaches is preferred if similar outcomes can be obtained.

An Intracardiac Mass in a Pregnant Woman Presenting With Ventricular Tachycardia.

A pregnant patient presented with symptomatic ventricular tachycardia. Echocardiography revealed a large intramyocardial mass. Surgical resection was attempted in conjunction with cryoablation of the surrounding myocardial tissue. Histologic examination of the resected mass revealed cardiac neurofibroma. To the best of our knowledge, this is the first report of cardiac neurofibroma in a pregnant patient in the absence of any neurocutaneous syndromes such as neurofibromatosis.

Aortic root replacement using a modified composite valve graft.

OBJECTIVES: We used a modified technique of a composite graft by moving the valve prosthesis away from the end into the inside of the tube and compared the effectiveness of this surgical method with the standard valved conduits. METHODS: Through a prospective nonrandomized clinical study between March 2011 and June 2012, we performed replacement of the aortic valve and ascending aorta in 30 consecutive patients using a valved composite graft with a mechanical valve prosthesis. A modified self-assembled valved composite graft was employed in 20 patients (Modified group), while the remaining 10 patients received the standard composite graft (Control group). RESULTS: There was significantly less bleeding in the patients with modified grafts (184 vs. 415 mL, p < 0.05). Moreover, the mean transvalvular gradient of the composite graft patients was lower in the modified group than in the control group (9 vs. 14 mmHg, respectively, p < 0.05). CONCLUSIONS: The modified valve composite graft technique results in good hemodynamics and appears to limit blood loss.

Long-term effect of papillary muscle approximation combined with ventriculoplasty on left ventricle function in patients with ischemic cardiomyopathy and functional mitral regurgitation.

OBJECTIVE: One of the mechanisms of development of functional mitral regurgitation after myocardial infarction is the increased papillary muscle distance which results due to ventricle remodeling. The aim of this study was to investigate the long-term effect of papillary muscle approximation (PMA) on the cardiac function of patients with ischemic cardiomyopathy and increased papillary muscle distance. METHODS: Thirty patients (22 males; mean age: 57.0 ± 7.4 years) selected for coronary artery bypass grafting (CABG) underwent ventriculoplasty. Additionally, 50% of the study population also underwent PMA (group 1). All the patients had preoperative grade 3 or 4 mitral regurgitation with an inter-papillary muscle distance > 2.5 cm. In group 1, the papillary muscles were drawn together using an encircling loop. Mitral annuloplasty and the Dor procedure were performed in all the patients. Follow-up time was 41.5 ± 5.8 months and 42.7 ± 3.3 months in groups 1 and 2, respectively (p-value=0.49). RESULTS: The two groups had no significant difference regarding the annulus diameter, ring size, number of grafts, and concavity area. There was one case of in-hospital mortality in each group, and one patient in group 2 had expired by the last follow-up. Postoperative echocardiography revealed significant changes in the concavity area, ejection fraction, and sphericity index in the PMA group by comparison to group 2 (p-value < 0.05). CONCLUSIONS: In patients with ischemic mitral regurgitation and increased papillary muscle distance, PMA as an adjunct to CABG results in better left ventricle function and shape, even at long-term follow-up.

Pericardial tamponade and right-to-left shunt through patent foramen ovale after epicardial pacing-wire removal.

After cardiac operations, careful management substantially reduces the risks of negative complications during or after the removal of temporary epicardial pacing wires. Herein, we report the case of a 58-year-old man who, 4 days after undergoing aortic root replacement, developed pericardial tamponade after the removal of temporary epicardial pacing wires. Consequent to the tamponade, a right-to-left shunt developed through a previously undiagnosed patent foramen ovale. The patient underwent emergency surgery to repair myocardium that had ruptured due to the removal of the wires, and he recovered uneventfully.

Papillary muscle repositioning in valve replacement for left ventricular dysfunction: ischemic mitral regurgitation.

BACKGROUND: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regurgitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics. METHODS: We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function. RESULTS: The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p < 0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p > 0.05). CONCLUSIONS: The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced.

Echocardiographic approach to the decision-making process for tricuspid valve repair.

OBJECTIVE: Commonly used procedures to repair functional tricuspid regurgitation have a high failure rate. The present study was designed to lower this failure rate by reducing leaflet tethering via pericardial patch augmentation when the preoperative probability of recurrence was high. METHODS: Between 2001 and 2007, 210 patients with severe functional tricuspid regurgitation underwent tricuspid valve repair at the Day General Hospital. With respect to the type of repair, the patients were randomly divided into 4 groups: (1) De Vega in 52 patients; (2) ring annuloplasty in 53 patients; (3) De Vega and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 53 patients; and (4) ring annuloplasty and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 52 patients. The results of 1-month and 1-year postoperative tricuspid regurgitation were evaluated. RESULTS: Fifteen patients in group 3 and 15 patients in group 4 met the criterion for the complementary procedure. Postoperative tricuspid regurgitation was different between the groups (P < .05): 16.0% and 28.0% of patients in the De Vega group, 8.0% and 14.0% of patients in the ring annuloplasty group, 4.0% and 10.0% of patients in the De Vega + pericardial patch augmentation group, and 2.0% and 8.0% of patients in the ring annuloplasty + pericardial patch augmentation group had postoperative tricuspid regurgitation at 1-month and 1-year follow-up, respectively. CONCLUSION: An assessment of preoperative tricuspid valve tethering to select patients suitable for augmentation contributes to a good surgical outcome in patients with severe functional tricuspid regurgitation.

Prevention of atrial fibrillation after coronary artery bypass grafting via atrial electromechanical interval and use of amiodarone prophylaxis.

In our previous study, we defined a cut-off point of 120 ms for atrial electromechanical interval (AEMi) to determine the risk of atrial fibrillation (AF) occurrence. Accordingly, the present study sought to investigate whether or not a prophylactic perioperative administration of amiodarone could reduce the incidence of AF in a high-risk group (AEMi >120 ms) undergoing coronary artery bypass grafting (CABG). In this prospective, randomized study, 100 patients with AEMi >120 ms received either amiodarone (n=50) or placebo (n=50). The endpoints were AF occurrence after CABG and hospital and intensive care unit (ICU) lengths of stay after CABG. The incidence of postoperative AF was significantly higher in the placebo group than that of the amiodarone group (88% of patients in control group vs. 16% of patients in amiodarone group, P<0.0001). The prophylactic therapy with amiodarone significantly reduced the ICU length of stay (2.28+/-1.00 vs. 3.60+/-0.90 days, P<0.0001) and hospital length of stay (5.64+/-2.35 vs. 7.78+/-1.46 days, P<0.0001). The incidence of postoperative AF among patients with high AEMi was significantly reduced by a prophylactic amiodarone treatment, resulting in shorter ICU and hospital stays.

Decreased right ventricular function after coronary artery bypass grafting.

Decreased right ventricular function after coronary artery bypass grafting is a common and well-known (if not well-understood) phenomenon.We prospectively evaluated right ventricular function via echocardiographic tricuspid annular motion, tricuspid annular velocity, and right ventricular strain analysis before and after coronary artery bypass grafting. We also evaluated the effect of right coronary artery disease and revascularization on post-coronary artery bypass grafting, right ventricular function, and interventricular septal motion.We performed baseline echocardiography in 250 candidates for coronary artery bypass grafting, and we repeated echocardiography in 240 of those patients 1 year after coronary artery bypass grafting. We evaluated right ventricular function via tricuspid annular motion, tricuspid annular velocity, and right ventricular strain analysis, all measured at the right ventricular free wall.Right ventricular function as evaluated by tricuspid annular motion showed a significant reduction 1 year after coronary artery bypass grafting (21.7 vs 12.1 mm; P < 0.001) compared with preoperative measurements. Right ventricular tissue velocity (14.0 vs 7.0 cm/s; P < 0.001) and right ventricular strain (20.3% vs 11.6%; P < 0.001) were also significantly reduced after coronary artery bypass grafting. Interventricular septal motion was paradoxical in 97% of the patients 1 year after coronary bypass.Right ventricular function remained depressed for as long as 1 year after coronary artery bypass grafting. These findings were independent of the state of the right coronary artery and the graft. It is likely that the interventricular septum is recruited to maintain right ventricular stroke volume after coronary artery bypass grafting.

Interaction between two predictors of functional outcome after revascularization in ischemic cardiomyopathy: left ventricular volume and amount of viable myocardium.

OBJECTIVE: In patients with ischemic cardiomyopathy and substantial amounts of dysfunctional but viable myocardium, revascularization cannot always improve the left ventricular ejection fraction. We sought to investigate the interaction between the left ventricular volume and the amount of viable myocardium to predict the left ventricular ejection fraction increase after revascularization. METHODS: Eighty-five consecutive patients with a depressed left ventricular ejection fraction (mean: 27.3% +/- 5.2%) underwent coronary artery bypass grafting after a dobutamine stress echocardiography had determined that they had at least 4 viable segments. Six months after coronary artery bypass grafting, left ventricular ejection fraction and regional wall motion were reassessed. RESULTS: Although the left ventricular ejection fraction was expected to recover more than 5% in all 85 patients after coronary artery bypass grafting, it did not improve in 15 patients (17.6%) despite the presence of viable segments. The likelihood of the left ventricular ejection fraction recovery decreased proportionally with an increase in the left ventricular end-systolic volume. The nonimprovers had a higher left ventricular end-systolic volume (164.2 +/- 22.4 mL vs 125.6 +/- 23.4 mL, P = .0001). In addition, the number of viable segments during the dobutamine stress echocardiography had a significant correlation with the ejection fraction increase after 6 months (P < .0001). Patients with 6 viable segments showed a good outcome irrespective of their left ventricular end-systolic volume. In patients with fewer than 6 viable segments, left ventricular end-systolic volume was a major factor in the prognosis: Patients with left ventricular end-systolic volume of 145 or more had a poor left ventricular ejection fraction increase and vice versa. CONCLUSION: The extent of left ventricular remodeling determines the rate of functional improvement after coronary artery bypass grafting. Patients with a high left ventricular end-systolic volume and fewer than 6 viable segments have a lower likelihood of improvement.

Prediction of atrial fibrillation via atrial electromechanical interval after coronary artery bypass grafting.

BACKGROUND: We assessed the validity of the atrial electromechanical interval, measured by transthoracic tissue Doppler echocardiography, in determining patients at risk of post-coronary artery bypass graft atrial fibrillation (AF). METHODS AND RESULTS: This prospective study recruited 355 patients in sinus rhythm who were candidates for coronary artery bypass grafting. The patients underwent a preoperative transthoracic echocardiography with a tissue Doppler evaluation and were monitored with continuous ECG telemetry during their hospital stay. Sixty-eight patients had postoperative AF (19.2%), with the incident occurring 2.3+/-0.7 days after surgery. The median length of hospitalization was 7.0 days for the AF patients and 6.0 days for the non-AF patients (P<0.0001). The subjects with postoperative AF differed from the sinus rhythm patients in that the former had a lower ejection fraction (40.4+/-8.5% versus 48.4+/-9.4%), a reduced maximal A-wave transmitral Doppler flow velocity (44.3+/-4.6 versus 53.3+/-10.9 cm/s), an increased total atrial volume (68.7+/-12.6 versus 55.3+/-11.8 mL), and a prolonged atrial electromechanical interval (141.9+/-13.4 versus 100.3+/-10.3 ms, respectively; P<0.0001 for all). In addition, the AF patients were older than the sinus rhythm group (66.0+/-8.0 versus 59.8+/-8.5 years). The atrial electromechanical interval was the best independent discriminator of the history of AF. We defined a cutoff point for the atrial electromechanical interval and chose 120 milliseconds for categorization, which yielded 100% sensitivity and 94.8% specificity for the prediction of AF. CONCLUSIONS: The atrial electromechanical interval by transthoracic tissue Doppler echocardiography could be a valuable method for identifying patients vulnerable to post-coronary artery bypass graft AF.

A prospective study of predicting factors in ischemic mitral regurgitation recurrence after ring annuloplasty.

BACKGROUND: Ischemic mitral regurgitation (IMR) is a complex lesion to repair, and its successful management requires an understanding of its mechanism and severity. Ring annuloplasty, currently the surgical treatment of choice for IMR, has failure rates as high as 30% in patients with functional IMR. We sought to study the variables that can predict IMR recurrence after ring annuloplasty. METHODS: This is a prospective study of 114 patients with 3+ to 4+ IMR who underwent coronary artery bypass grafting and mitral valve annuloplasty with acceptable results at an approximately 2-year follow-up. Variables were compared in a failure group, comprising patients with 2+ or higher MR and a nonfailure group, consisting of those with less than +2 MR. RESULTS: There were five postoperative in-hospital deaths. During follow-up, 14 patients died and 95 patients were evaluated. After a mean follow-up of 22.2 +/- 4.6 months for the nonfailure group and 18.6 +/- 5.6 months for the failure group, 23 patients (24.4%) exhibited annuloplasty failure. Some variables had an effect in our univariate analysis, but only interpapillary muscle distance had a relationship with recurrent MR in the multivariate analysis. Mean preoperative interpapillary muscle distance was 15.0 +/- 4.0 and 26.5 +/- 2.9 in the nonfailure group and failure group, respectively (p < 0.0001). CONCLUSIONS: Interpapillary muscle distance, as a reliable index of dysfunctional subvalvular apparatus in patients with IMR, can predict late postrepair MR and indicate the need for a procedure complementary to annuloplasty.

Preoperative determination of artificial chordae length.

We present a practical and accurate way to measure artificial chordae length in mitral valve repair. During preoperative transesophageal echocardiography, the distance between the head of the posterior papillary muscle and the mitral annulus plane at the coaptation of the leaflets is measured; this is the length of the new chorda. Every millimeter of braided 4-0 Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) contains two tight reverse knots; therefore, the number of the knots determines the accurate length of the artificial chorda.

Abdominal aorta screening during transthoracic echocardiography.

OBJECTIVE: The purpose of this study was to investigate the use of a modified abdominal ultrasound examination, performed as an extension of a routine diagnostic transthoracic echocardiography. This modified examination is arguably a simple, safe, quick, and accurate way to identify patients with abdominal aortic aneurysm (AAA). METHODS: This prospective study, conducted over a 6-month period, sought to obtain the maximum diameter of the abdominal aorta through a routine transthoracic echocardiography. RESULTS: In 1285 patients, 1175 abdominal aortas were visualized (91.4%). The prevalence of AAA was 3.8% (45/1175), which increased with age. Six patients, who had diameters more than 5 cm, were referred to a surgeon. In the patients with AAA, left ventricular hypertrophy and left ventricular dilatation were more frequent. CONCLUSION: Routine screening of the abdominal aorta during transthoracic echocardiography is recommended on account of the prevalence of AAA in unselected and, in particular, older patients.

Papillary muscle repositioning in mitral valve replacement in patients with left ventricular dysfunction.

BACKGROUND: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning for mitral valve replacement procedures in patients with left ventricular dysfunction and to determine the early and late effects of this procedure on clinical outcome and left ventricular mechanics. METHODS: One hundred patients with ejection fraction less than 40, who were candidates for isolated surgical correction of mitral insufficiency, had mitral valve replacement and were prospectively randomly assigned to either total chordal-sparing or papillary muscle repositioning. Fifty subjects underwent papillary muscle repositioning (PMR group), and the remaining 50 had complete preservation of all chordal structures with mitral valve replacement (CMVR group). Echocardiography was performed preoperatively, at discharge, and after 2 years to determine dimensions, left ventricular shape, and function. RESULTS: End-diastolic and -systolic volumes decreased in both groups initially and continued to decline. Decreasing volumes, however, were more significant in the PMR group, in which the significant decrease in the sphericity index continued for another 2 years. In contrast, the sphericity index in the CMVR group had no significant changes at discharge and at 2 years. In terms of systolic performance, ejection fraction had no significant changes in the CMVR group, whereas ejection fraction significantly increased in the PMR group. CONCLUSIONS: Papillary muscle repositioning may result in more favorable left ventricular remodeling compared with complete retention of the mitral subvalvular apparatus during mitral valve replacement. It confers a significant early and late advantage by causing significant reductions in the left ventricular chamber volume, sphericity index, and systolic performance.

Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG.

The optimal management of moderate (grade 2-3+) ischemic mitral regurgitation (MR) in patients undergoing coronary artery bypass grafting (CABG) remains controversial. While CABG alone can reverse regurgitation in some patients with moderate MR, adjunctive mitral repair may be necessary in others. We performed low-dose dobutamine stress echocardiography (DSE) in 60 patients with moderate MR who were about to undergo CABG. Group I, 25 patients who demonstrated reduction in MR during DSE, had CABG alone. Group II, 35 patients in whom MR was unchanged during DSE, had mitral valve repair as well as CABG. MR was reduced postoperatively in both groups (P < 0.0001). Postoperative ejection fraction in Group I (12.2%) improved more than that in Group II (9.3%) (P < 0.01). We conclude that CABG alone may be sufficient to correct moderate MR when MR is reduced during DSE.

Papillary muscle approximation combined with ventriculoplasty in patients with ischemic cardiomyopathy and functional mitral regurgitation: effects on mitral valve and LV shape.

Recent studies define functional mitral regurgitation (MR) and worsened left ventricular (LV) systolic indices as the widening of the dimension between papillary muscle heads; consequently, narrowing this distance may improve the mitral valve and LV function. Thirty (22 males; mean age: 57+/-7 years) candidates for CABG underwent ventriculoplasty and in 50% of them papillary muscle approximation was also performed (group 1). All the patients had grade 3 to grade 4 MR with an interpapillary muscle distance of more than 2.5 cm. In group 1 the papillary muscles were drawn together by an encircling loop using a 4-mm Gore-Tex tube or umbilical tape. Mitral annuloplasty and Dor procedures were performed in all the patients. Postoperative echocardiography revealed significant changes in systolic and diastolic sphericity indices in the PMA group. There was one hospital death in each group, and within a short mean follow-up period of 9 months, there were no late deaths. Improvement of NYHA class and MR were significantly better in the PMA group. Papillary muscle approximation in selected patients has a clear effect on the mitral valve and LV shape by reducing tethering and sphericity due to the displacement of the papillary muscles.