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Heart Jo
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According to the ruling of the Medical Sciences Publications Commission No. 14313-80/10/1 and 36914-85/2/10 signed by the Minister of Health and Medical Education and the Head of the Medical Sciences Publications Commission of the Islamic Republic of Iran, this journal has been granted accreditation as a scientific-research journal. This Journal is indexed in the Scientific Information Database (WWW.SID.IR) and IMEMR and Index COPERNICUS, SCOPUS, CINAHL and Google Scholar.
ISSN: 1735-7306
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OFFICIAL QUARTERLY PUBLICATION OF THE IRANIAN HEART ASSOCIATION
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Executive Board:
Chairman: Editor-in-Chief: Executive Manager: Feridoun Noohi, MD A. Hussein Tabatabaei, MD Majid Maleki, MD
Technical Editors: Associate Editors: Assistant Manager: Farshad Amouzadeh, MA Rasoul Azarfarin, MD Shahin Shrani, MD
Hooman Bakhshandeh, MD Shabnam Madadi, MD Reza Golpira, MD
Local Editorial Board: Abdi S. Gholampour Dehaki M. Maleki M. Peighambari M. M. Ahmadi H. Hagh Azali M. Mandegar M. H. Pezeshkian M.
Alizadeh Ghavidel A. R. Haghjoo M. Mehranpour M. Poorhosseini HR
Alizadeh Sani, Z Haj Sheikholeslami F. Mohagheghi A. Pourmoghaddas M. Aminian B. Haji Zeinali AM. Mohebbi A. Radpour M.
Arefi H. Hakim H. Mojtahedzadeh S. Sadeghi M.
Azarfarin R. Handjani A. M. Momtahen M. Sadeghpour Tabaee A. Azarnik H. Hashemi J. Mortezaeian H. Sadr Ameli M. A.
Baghezadeh A. Hashemian M. Mostafavi A. Sadeghpour A.
Baharestani B. Heidarpour A. Motamedi M. R. Sattarzadeh R. Bakhshankdeh H. Hosseini K. Nabavizadeh Rafsanjani F. Shahmohammadi A.
Bassiri H. Hosseini S. Navabi M. A. Shakibi J.
Bolourian A. Javidi D. Nazeri I. Shirani SH. Eslami M. Jebbeli M Nematipour E. Tabatabaei A. H.
Farasatkish R. Kalantar Motamedi M. H. Nikdoost F. Tabatabaei M. B.
Firouzabadi H. Karimi A. Nozari Y. Yousefi A.A. Firouzi A. Kazemi Saleh D. Ojaghi Haghigi S. Z. Youssefnia M. A.
Firouzi I. Kamal hedayat D. Noohi F. Vahedian J.
Ghaffari Nejad M. H. Kiavar M. Omrani G. Zavarehee A.
Ghasemi M. Madadi Sh. Oraii S. Zand parsa A.F.
International Editorial Consultants:
Alipour M. USA Karim S. Indonesia Pavie A. France
Anderson D. UK Khaghani A. UK Qureshi S. A. UK Bagir R. USA Koolen J. Netherlands Razavi M. USA
Bellosillo A. Phillipines Kranig W. Germany Robin J. France
Davis W. UK Kusmana D. Indonesia Sadeghi A. USA Deutsch M. Austria M Samuel. India Samad A. Pakistan
Djavan S. Austria Malek J. USA Sheikh S. Pakistan
Domanig E. Austria Marco J. France Sheikhzadeh A. Germany Dorosti K. USA Mee R. USA Shenasa M. USA
Elliott M. UK Mirhoseini M. USA Siddiqui H. India
Estafanous F.G. USA Monga M. S. Pakistan Sloman G. Australia Foale R. UK Moosivand T. Canada Smith W. M. New Zealand
Gandjbakhch I. France Moten M. USA Tajik A. J. USA
Jahangiri M. UK Nagamia H. USA Tynan M. UK Jazayeri M.R. USA Otto A. Turkey Wolner E. Austria
Contributing Editors of This Issue:
Abdi S. Jebbeli M Mandegar M. H. Peighambari M. M.
Azarfarin, R. Kamal hedayat D. Mohebbi A. Sadr Ameli M. A. Bassiri H.A. Madadi, Sh. Noohi F. Shirani, Sh.
Hosseini S. Maleki M. Omrani G.R. Tabatabaei A. H.
Technical Typist: F. Ghomi
Secretary: A. Beheshti
Address: Iranian Heart Association: P.O. Box: 15745-1341, Tehran, I.R. Iran. Tel: (009821) 22048174, Fax: (009821)
22048174
E-mail: [email protected]
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EDITORIAL
In the Name of God, the Most Beneficent, the Most Merciful
Dear colleagues and friends,
We are delighted to present to you Volume 17, Number 4 (Winter, 2017) issue of The Iranian
Heart Journal, which contains some interesting new studies and case reports in the domains of
cardiovascular medicine and surgery from our colleagues across Iran.
The Iranian Heart Journal is indexed in the Scientific Information Database (WWW.SID.IR),
IMEMR, Index Copernicus, Scopus, and CINAHL, thereby facilitating access to published
literature. There is no doubt, however, that our journal requires your opinions, ideas, and
constructive criticism in order to accomplish its main objective of disseminating cutting-edge
medical knowledge.
As ever before, we continue to look forward to receiving your latest research and cases.
Yours truly,
A. Hussein Tabatabaei, MD F. Noohi, MD
Editor-in-Chief, Chairman,
The Iranian Heart Journal The Iranian Heart Journal
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Volume 17, Number 4
Winter, 2017
CONTENTS:
Page
ORIGINAL ARTICLES: CLINICAL SCIENCE
Assessment of Long- and Short-Term Complications of Percutaneous Patent Foramen Ovale
Closure in Patients With Cerebrovascular Events or Peripheral Embolism Over a 12-Year
Period Starting in 1998
Mohsen Madani, MD; Faramarz Amiri, MD; Mohammad Kazem Maher, MD; Ali Zahedmehr,
MD; Bahram Mohebi, MD; Jamal Moosavi, MD
6-16
Relationship Between the Pulmonary Artery Pressure and the Occurrence of Atrial
Fibrillation After Coronary Artery Bypass Graft Surgery
Somayeh Beikmohammadi, MD; Hamid Reza Sanati, MD; Mohammad Mehdi Peighambari,
MD; Mohammad Mostafa Ansari-Ramandi, MD; Mehrdad Azimi, MD; Ali Zahedmehr, MD;
Ata Firouzi, MD; Reza Kiani, MD; Farshad Shakerian, MD; Omid Shafe, MD
17-20
Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block
Vajihe Dorosti, MD; Ata Firouzi, MD; Hossein Torabi Golsefid, MD; Alireza Jebeli, MD
21-25
A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in Rajaie Cardiovascular,
Medical, and Research Center:7 Years’ Experience
Mohammad Ali Sadr-Ameli, MD; Tahereh Zandi Kermanshahi, MD; Mohammad Mehdi
Peyghambari, MD; Mandana Amir Sardari, MD; Hooman Bakhshandeh, MD; Maryam
Shojaeifard, MD; Masoomeh Fooladi, MD; Maryam Moradian, MD
26-29
Postoperative Outcome of the Transcatheter Closure of Atrial Septal Defects Using the
AMPLATZER Septal Occluder
Marzieh Nasiri Brojeni, MD; Parisa Seilani, MD; Mozhgan Parsaee, MD; Sedigheh Saedi, MD
30-35
Effects of a Nursing Supportive Program on Anxiety and Stress Levels in the Family Members
of Patients After Cardiac Surgery in the ICU
Tayebe Rezaei, MS; Rasoul Azarfarin, MD; Ziae Totonchi, MD; Hooman Bakhshandeh , MD;
Azin Alizadehasl, MD; Solmaz Fakhari, MD
36-41
Echocardiographic Evaluation of Right Ventricular Function After Pulmonary Valve
Replacement in Patients With Tetralogy of Fallot
Maryam Moradian, MD; Nooraldin Momeni, MD; Behshid Ghadrdoost, MS; Hojat
Mortezaeian, MD; Mohamad Rafi Khorgami, MD
42-48
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CONTENTS: Page
CASE REPORT
Development of Heart Failure Following Pace Maker Implantation in a Patient With
Congenital Heart Block
Kobra Doostali, MD; Sedigheh Saedi, MD; Tahereh Saedi, MD
49-52
Anomalous Trifurcation of the Left Main Coronary Artery: A Case Report
Daryoush Saed, MD; Peyman Arasteh, MD; Mehran Purnazari, MD
53-56
INSTRUCTIONS FOR AUTHORS 57-60
FORTHCOMING MEETINGS 61-64
SUBSCRIPTION FORM 65-66
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Long- and Short-Term Complications of Percutaneous PFO Closure in Patients With Cerebrovascular Events or Peripheral Embolism Madani M, et al.
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Original Article Long- and Short-Term Complications of Percutaneous PFO Closure in Patients With Cerebrovascular Events or Peripheral Embolism Madani M, et al.
Assessment of Long- and Short-Term Complications of
Percutaneous Patent Foramen Ovale Closure in Patients With
Cerebrovascular Events or Peripheral Embolism Over a 12-Year
Period Starting in 1998
Mohsen Madani
1, MD; Faramarz Amiri
2, MD; Mohammad Kazem Maher*
1, MD;
Ali Zahedmehr1, MD; Bahram Mohebi
1, MD; Jamal Moosavi
1, MD
ABSTRACT
Background: Observational studies have favored percutaneous patent foramen ovale (PFO) closure
over medical treatment for the reduction of recurrent stroke, whereas randomized trials have
failed to demonstrate the significant superiority of percutaneous PFO closure. A few long-
term studies are available on post-PFO closure outcome. This study reports long- and short-
term clinical outcomes after percutaneous PFO closure.
Methods: Between January 1998 and January 2015, we enrolled 51 (32 men [62.7%] and 19
[37.3%] women) consecutive eligible patients with cerebrovascular events or peripheral
embolism, presumably related to PFOs, who underwent percutaneous PFO closure in our
center. All the patients’ documents and clinical data were assessed. Of the entire study
population, telephone contacts were applied in 47 cases. The mean follow-up time was
46.51 ± 43.43 months. The main criterion for closure was patients with at least 1
cryptogenic stroke or peripheral embolism associated with PFOs.
Results: Percutaneous PFO closure was successfully performed in 51 patients. No cardiovascular or
cerebrovascular deaths occurred. The mean follow-up time was 46.51 ± 43.43 months.
Long-term device-related complications were cerebrovascular accidents in 3 (5.88%)
patients (2, 3, and 4 y after the procedure) and open heart surgery in 1 (1.96%). The short-
term complications were atrial fibrillation in 1 (1.96%) patient, air embolism in 2 (3.92%),
hematoma in 2 (3.92%), and tamponade in 1 (1.96%).
Conclusions: Percutaneous PFO closure was associated with a very low risk of recurrent stroke.
We observed no cardiovascular or cerebrovascular mortality; however, there were a few
short- and long-term device-related complications. Thus, percutaneous PFO closure is a safe
treatment even in the long term. (Iranian Heart Journal 2017; 17(4): 6-16)
Keywords: Patent foramen ovale ● Cryptogenic stroke● Long-term follow-up● PFO closure● Short-term follow-up●
Atrial septal aneurysm● Transient ischemic attack● Transesophageal echocardiography
1 Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I. R. Iran. 2 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I. R. Iran.
*Corresponding Author: Mohammad Kazem Maher, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical
Sciences, Niayesh Highway, Valiasr Street, Tehran, I.R. Iran.
E-mail: [email protected] Tel: 09125015241
Received: March 7, 2016 Accepted: July 15, 2016
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patent foramen ovale (PFO) is a
common heart defect presenting in
about 25% of the general population. 1
A few studies have shown the relationship
between PFOs and cryptogenic stroke in
young adults. Likewise, an association
between an increased risk for recurrent
thromboembolic events, PFOs, and
cryptogenic stroke has been previously
described. 2-5
PFOs and atrial septal
aneurysms are associated with an increased
risk of recurrent thromboembolic stroke, and
a large PFO is a predictor for cerebrovascular
ischemic events. 6-9
Long-term oral
anticoagulation or antiplatelet medication,
surgical PFO closure, and percutaneous PFO
closure with a catheter-based procedure using
a septal occluder device are considered the
potential therapeutic strategies for the
secondary prevention of paradoxical embolic
stroke. Percutaneous PFO closure is a safe,
feasible, and practical procedure. 10-13
Numerous different devices are used at
present. Five observational trials have
indicated that, in comparison to medical
treatment, the device closure of PFOs reduces
the relative risk of recurrent cerebrovascular
events by nearly 80%. 14-18
Nevertheless, 3
randomized trials 19-21
have shown no
significant benefits of device closure over
medical therapy during a 2-year follow-up.
The primary outcomes of the most recent
trials such as the RESPECT and the PC Trial
were not significantly affected by which
treatment was given. Low annual rates of
recurrent stroke (1%–2%) have been reported
by previous research, 22-23
citing the long-term
clinical outcomes of device closure and
showing a need for much larger follow-up
studies—either by enrolling more patients or
by maintaining a longer follow-up period.
Confusing results can be avoided by keeping
the number of patients lost to follow-up to a
minimum, especially when the event rate is
low. In observational studies, the
AMPLATZER PFO Occluder has been shown
to have advantageous safety features as a
closure device. 24
The aim of the present study was to provide
short- and long-term clinical follow-ups of
patients with a previous percutaneous PFO
closure as a secondary prevention after
cryptogenic stroke or peripheral embolism
and to monitor mortality, complications,
recurrent stroke, and other clinical significant
conditions.
METHODS
Patient Selection The present study, conducted between
January 1998 and January 2015, recruited 51
consecutive patients (32 [62.7%] men and 19
[37.3%] women), who were referred to our
tertiary care center for percutaneous PFO
closure. In all the patients, cryptogenic stroke
or transient ischemic attack (TIA) or
peripheral embolism associated with PFOs
were diagnosed by their neurologists and
cardiologists at primary local hospitals via
transesophageal echocardiography (TEE),
computerized tomography scan, or magnetic
resonance imaging of the brain. The patients
were referred from their 1st hospitals due to
the complexity of their cryptogenic stroke and
PFOs, and further evaluation of the patients’
clinical data and medical records was made
by our interventional cardiologists, who took
the final decision on PFO closure after
consulting TEE imaging experts and stroke
experts. For both index stroke/TIA and at
follow-up, a diagnosis of TIA was made by
the treating neurologist if acute neurological
deficits with a probable vascular ischemic
cause were completely resolved within 24
hours. Ischemic stroke was defined as a
sudden new focal neurological deficit lasting
> 24 hours. 25
Stroke etiology was defined
according to the modified TOAST (Trial of
Org 10172 in Acute Stroke Treatment)
criteria. 26
The documents and clinical records of 51
patients were assessed. Forty-seven cases
were followed up by telephone calls. In 4
A
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cases, telephone contact was not possible, so
they were only followed up through their
records. The main criterion for closure was
patients with at least 1 cryptogenic stroke or
embolic event with PFOs as no clear cause for
stroke or embolic event was found such as
atrial fibrillation, myocardial infarction during
the preceding 4 weeks, and large apical
infarction. The present study was approved by
the Review Board of Iran University of
Medical Sciences, Tehran, Iran. Informed
consent was obtained from the whole study
population. Twenty-eight cases had already
discontinued their medication at the time of
telephone intervention follow-up, and 3 of
those patients developed cerebrovascular
complications and were, therefore,
administered aspirin (ASA). Our results
demonstrated that after PFO closure, while we
had discontinued the medication, the rate of
recurrent events was very low.
Patent Foramen Ovale Closure
The patients, who were selected for PFO
closure, underwent TEE. The PFO size and
the underlying diseases were all assessed via
echocardiography. PFO closure was
performed under fluoroscopy guidance
without using TEE. The femoral vein access
was achieved in 27 patients. The
AMPLATZER, Figulla, Cardi-O-Fix, and
other devices were applied in the patients for
PFO closure. Out of the 51 patients, 39 cases
underwent transthoracic echocardiography
(TTE) and TEE for a 2nd time and were
evaluated regarding residual shunting and
location of the device during the 1st 48 hours.
The complications of death, bleeding
requiring blood transfusion, tamponade, air
embolism, arrhythmias, device embolization,
device thrombosis, arteriovenous fistula
formation, shunts before and after the
procedure, pseudoaneurysms, endocarditis,
cerebrovascular accidents (CVAs), and
embolic events were all assessed.
Patients’ Follow-Up
TEE was also performed 48 hours following
PFO closure with color Doppler and contrast
injections during the Valsalva maneuver in 39
patients. Residual shunting was defined as
“small” when 1–20 bubbles were seen in the
left atrium or when the shunt was seen only
with color Doppler, despite multiple contrast
injections during the Valsalva maneuver.
Once in excess of 20 bubbles were seen in the
left atrium, the shunt was considered
substantial. 28
The patients underwent
treatment with ASA and Plavix for the
duration of 6 months after PFO closure.
A structured medical history—including
items on recurrent stroke/TIA, risk factors for
stroke, and potential complications to
percutaneous treatment—was obtained from
all the patients. The patients who agreed to
attend follow-up at our center were examined
via ECG and TTE. The patients’ neurological
status was assessed using the modified
Rankin Scale. 29-31
Those who could not
attend our tertiary care center were followed
up with a structured telephone interview.
We collected all relevant medical records and
documentation of the imaging procedures
between 1998 and 2015 by a professional
interventionist. Forty-seven (92%) cases were
followed up by telephone. The entire study
population received ASA and Plavix
treatment. Atrial fibrillation rhythm before
and after the procedure, PFO diameter, tunnel
length > 10 mm or < 10 mm, presence of
coronary artery disease, other diagnostic
problems such as left ventricular clot or
concomitant disease, existence of thrombosis
on the PFO on echocardiography, and finally
occurrence of stroke as well as its type and
status on imaging were also determined.
Statistical Analysis
The continuous data are summarized as
means ± SDs (or median ranges), as
appropriate. Univariate comparisons were
made using paired or unpaired t-tests for the
continuous data and the Fisher exact test or
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the χ2
test for the categorical data. The level of
significance was considered at a P value <
0.05. The distributions are presented as means
and SEMs. The logistic regression test was
applied to remove the confounding effects of
the variables. The statistical analyses were
performed using SPSS, version 18.0 (software
IBM Corporation, Armonk, NY, USA).
RESULTS
In the present study, carried out between
January 1998 and January 2015, 51
consecutive patients—comprising 32 men
(62.7%) and 19 (37.3%) women—who were
referred to our tertiary care center for PFO
closure were enrolled. The mean age at PFO
closure was 39.61 ± 0.38 years (age range =
16–66 y). The mean follow-up duration was
46.51 ± 43.43 months (1–230 mon).
Among the 51 patients, the minor
complications were comprised of atrial
fibrillation (n = 1, BioSTAR), hematoma (n =
2, AMPLATZER Occluder and Figulla), and
air embolism (n = 2, Figulla). Among these
patients, there was a 29-year-old man with a
previous history of pulmonary stenosis. He
underwent percutaneous transluminal
pulmonary commissurotomy (PTPC) but
suffered intraprocedural tamponade due to
right atrium-inferior vena cava (RA-IVC)
rupture and finally underwent surgery. The
major complications were device removal 1
year after closure in 1 patient (AMPLATZER
Occluder) with a PFO size of 3 mm and mild-
to-moderate residual shunting after PFO
closure on follow-up echocardiography, CVA
in a 47-year-old man (Figulla device) with a
PFO diameter of 4.5 mm and a PFO length of
12 mm and unknown shunting 2 years after
closure, and CVA in a 35-year-old patient
with a PFO diameter of 8 mm without
residual shunting 4 years after PFO closure
(25-mm DEVIE device). There was also a 32-
year-old patient, who experienced CVA 3
years after PFO closure and had a history of 2
cerebrovascular events. This patient had
pulmonary stenosis, for which he underwent
PTPC but developed intraprocedural
tamponade. The diameter of the PFO was 4
mm in 1 case with the Figulla device and after
closure, there was no residual shunt. All the
mentioned complications were not
accompanied by underlying diseases apart
from 1 patient, who had pulmonary stenosis,
experienced tamponade because of RA-IVC
junction rupture, and suffered 2 CVAs within
a 3-year period afterward. The device most
frequently used in the patients was the Figulla
in 28 (54.9%) cases and the AMPLATZER
Occluder in 12 (23.5%). The average PFO
diameter was 3.49 ± 1.38 mm (min of 1 mm
and max of 8 mm), and the mean length of the
PFO was 11.61 ± 6.02 mm (min of 5 mm and
max of 24 mm). Out of the 51 patients, 20
(39.2%) cases had hemiparesis associated
with dysarthria, 18 (33.3%) had hemiparesis,
and 2 (3.9%) had visual loss. ASA was used
totally in 8 (11.8%) cases. According to the
study population’s medical records, among
the 51 cases, TIA was seen in 10 (19.6%),
CVA in 37 (72.5%), TIA in conjunction with
CVA in 3 (5.9%), and peripheral embolism in
12% of the cases. Furthermore, among the 51
patients, PFOs with atrial septal aneurysms
were seen in 8 (11.8%) cases. Diabetes
mellitus was seen in 11.96% of the patients,
hypertension in 6 (11%), smoking in 6
(11.76%), and hyperlipidemia in 6 (11.8%).
The most frequently used drugs were
respectively ASA in 15 (29.4%) cases, Plavix
and ASA in combination in 14 (27.5%),
warfarin in 9 (17.6%), ASA and warfarin in 8
(15.7%), and Plavix in 1 (2%). Out of the 51
patients, 41 cases had PFO closure while they
experienced their 1st embolic events and in 10
cases, PFO closure was performed when they
had recurrent cerebrovascular events (Table
1).
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Table 1. Demographic and clinical data
Variables Mean ± SD N=51
Age 36.61±0.38 (16-66 y)
Sex male female
32 (62.7%) 19 (37.3%)
DM 11.96%
HTN 6 (11%)
Smoking 6 (11%)
Hyperlipidemia 6 (11.8%)
ASA 15 (29.4%)
Warfarin 9 (17.6%)
Warfarin + ASA 8 (15.7%)
Plavix ± ASA 14 (27.5%)
Plavix 1 (1.96%)
No anticoagulant 4 (7.84%)
Hemiparesis 18 (33.3%)
Dysarthria 8 (15.68%)
Hemiparesis + dysarthria 20 (39.2%)
Visual loss 2 (3.9%)
Peripheral embolism 1 (1.96%)
Unknown cerebrovascular symptoms 2 (3.9%)
ASA, Aspirin; HTN, Hypertension; DM, Diabetes mellitus
Short-Term Complications
According to our results, the short-term
complications were atrial fibrillation in 1
(1.96%) patient, air embolism in 2 (3.92%),
hematoma in 2 (3.92%), and tamponade in 1
(1.96%). Atrial fibrillation was seen in a 29-
year-old patient with a 23-mm BioSTAR
device
without any cardiac risk factors.
Hematoma was seen in 2 cases with the
Figulla device; 1 of these patients received
warfarin and the other one received ASA and
Plavix together. Air embolism was seen in 2
cases with the Figulla device. Tamponade was
observed in a 29-year-old man with the
Figulla device. He had pulmonary stenosis,
for which he underwent PTPC and due to
stroke was candidated for PFO closure.
During the procedure, however, tamponade
occurred owing to the rupture of the RA-IVC
junction and finally he underwent open heart
surgery (Table 2).
Table 2. Long- and short-term complications
Complication N(%) N=51
CVA 3 (5.88%)
Open heart surgery 1 (1.96%)
AF 1 (1.96%)
Tamponade 1 (1.96%)
Air embolism 2 (3.92%)
Hematoma 2 (3.92%)
CVA, Cardiovascular accident; AF, Atrial fibrillation
Long-Term Complications
The long-term complications were comprised
of CVAs, seen in 3 (5.88%) patients with
recurrent CVAs (2, 3, and 4 y afterward), and
residual shunting in 1 patient, who underwent
open heart surgery and device removal. No
death due to cardiovascular or
cerebrovascular events was seen. Out of the 3
cases with CVAs, the Figulla device was used
in 2 (66.6%) and the DEVIE device was
applied in 1 (33.3%). In the 2 cases, follow-up
echocardiography was performed and no
residual shunt was observed. Follow-up
echocardiography was not performed in the
other case. One patient had a history of
pulmonary stenosis and underwent PTPC.
Open heart surgery was performed in 1 male
patient due to residual cardiac shunting and he
was found to have a PFO diameter of 3 mm
but no history of underlying heart disease was
found. (The implanted device was the
AMPLATZER Occluder, and mild-to-
moderate residual shunting after PFO closure
was observed on follow-up
echocardiography.) Totally, the long-term
complications were observed in 4 patients: 1
patient underwent surgery for a 2nd time for
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PFO closure and 3 patients had CVAs (Table
2).
Incidence of the Underlying Diseases
Out of the 51 patients with PFOs, interatrial
septal aneurysms were seen in 6 (11.76%)
patients, lipomatous hypertrophy of the
interatrial septum (thickness = 4.9 mm) in 2
(3.94%), previous coronary artery bypass
graft surgery in 1 (1.96%), and history of
pulmonary stenosis and PTPC in 1 (1.96%)
(Table 3).
Table 3. Frequency of the long-term complications associated with the device,
PFO diameter, and residual shunts
Variables Device Type PFO
Diameter Follow-
Up Echo Shunt
CVA Open heart surgery
Figulla 4 mm yes no 2 (66.6%) 1 (33.3%) 1 (33.3%)
DEVIE 8 mm yes no
AMPLATZER 3 mm yes yes
PFO, Patent foramen ovale; CVA, Cerebrovascular accident
Table 4. Frequency of the underlying concomitant diseases
Type N(%) N=51
ASA 6 (11.75%)
Lipomatous hypertrophy of the septum 2 (3.94%)
Severe PS and PTPC 1 (1.96%)
CABG history 1 (1.96%)
No underlying disease 41 (80.39%)
ASA, Atrial septal aneurysm; PS, Pulmonary stenosis; PTPC, Percutaneous transluminal pulmonary commissurotomy; CABG, Coronary artery bypass graft surgery
Relationship between atrial fibrillation and
the device type
We found 1 instance of atrial fibrillation in a
23-year-old man with a BioSTAR device
without any risk factors.
Relationship between the device type and the
long-term complications (cerebrovascular
accidents and surgery)
A small-to-moderate residual shunt or
fenestration after PFO closure was found in 1
patient, who had PFO closure with the
AMPLATZER Occluder device (25 mm) and
underwent open heart surgery due to
continuous shunting 1 year after PFO closure.
The size of the PFO before closure was 3 mm,
and the patient had no history of underlying
heart diseases. Out of the 3 patients with
CVAs, 2 cases had the Figulla device and 1
had the DEVIE device. The Figulla was
utilized in a 45-year-old male smoker with a
PFO diameter of 4.5 mm; he had no residual
shunting on follow-up echocardiography. The
Figulla device was also used in a 29-year-old
man without any cardiac risk factors and with
a PFO diameter of 4 mm; he had no residual
shunting on follow-up echocardiography. The
DEVIE device was used only in a 31-year-old
man without any history of cardiac risk
factors and with a PFO diameter of 8 mm;
there was no residual shunting on follow-up
echocardiography (Table 3).
Frequency of cardiovascular accidents due
to remaining shunts
Out of the 51 patients, 39 cases had follow-up
echocardiography. Eight (20.51%) of these
patients had residual shunts on follow-up
echocardiography.
Frequency of the remaining shunts
according to the device type
There were 51 patients with considerable
residual shunts; 5 (9.80%) of these patients
had the Figulla device and 3 (5.88%) had the
AMPLATZER Occluder device.
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DISCUSSION
The rate of recurrent neurological events in
the present study is high in comparison with a
recently published meta-analysis of 48
studies, which showed a recurrence rate of
0.8% per year for PFO closure and 5% per
year for pharmacologically treated PFO
patients. 32
The recurrence rate of
complications for PFO closure in our study
was 1.5% annually. It should be noted,
however, that our sample size is too small.
PFO closure in a long-term follow-up study of
12.4 years was associated with a very low
recurrent event rate of 0.3% per year and a
success rate of 99%. According to our study,
the recurrence rate was about 1.5% in 1 year,
which is approximately twice that reported by
another 2 meta-analyses. The differences may
be more due to various inclusion criteria. In
our study, the recurrence rate of stroke was
low and the coincidence of PFOs and atrial
septal aneurysms was infrequent. Therefore, if
we had included high-risk patients, the
differences would have been reduced.
So far, there have been 3 randomized clinical
trials on device PFO closure. The 1st study,
CLOSURE I, 19
presented no significant
benefits of PFO closure on the primary end
point to prevent recurrent stroke but had a
trend toward a slight reduction in recurring
TIAs: 3.3% for PFO closure vs 4.6% for
medical therapy alone. The RESPECT trial 20
and the PC Trial 21
have both been published
recently and, as with the CLOSURE I study,
their primary outcome was not significantly
affected by which treatment was given.
However, the results of these studies should
be interpreted more carefully because the
event rate was lower than expected.
The present study provides reliable short- and
long-term follow-up and adds to our
understanding of the long-term consequences
of PFO closure in patients with a history of
cerebrovascular events associated with PFOs.
The mean follow-up post PFO closure was
46.51 ± 43.43 months. This is both short-term
and long-term clinical follow-ups of PFO
cases with a follow-up rate of 47 (92%)
according to telephone contacts with the
patients. The mean follow-up time in a study
by Fischer et al 22
was found to be 15.4 years,
but the follow-up rate was only 89% post
PFO closure. In addition, the mean follow-up
after index event in a study by Wahl et al 23
was 10 years, with a mean follow-up rate of
98%. When the event rate is low, it is of vital
importance to have a high follow-up rate in
order to eliminate the risk of bias. In the
present study, the follow-up rate according to
the patients’ documents and records was
100% and in terms of telephone contacts was
92%. The 10.47% incidence of atrial
fibrillation was the only potential procedure-
related minor complication in the present
study. However, the observed atrial
fibrillation was transient; no chronic atrial
fibrillation could be observed and it was
spontaneously recovered. The incidence of
atrial fibrillation varies in other studies from
0.6% 33
to 7.6% 34
during the 1st year post
PFO closure. Khairy et al 35
in 2003 reported
a rate of 7.9% for major complications and
1.5% for minor complications. In 2009, Wahl
et al 33
reported a complication rate of 0.8%.
In our study, the long-term event rate was 4
(7.84%) and the short-term event rate was 6
(11.76%). We also showed that the rate of
major complications was approximately in
concordance with that reported by the Khairy
trial; however, the rate of minor
complications was higher than that reported in
the trial, which may be due to the occurrence
of air embolism and hematoma during the
procedure. The reduction in the complication
rate over time is most likely a result of better
patient selection, better devices, and greater
experience among interventional
cardiologists. 36
It is supposed that clinical results will be
more optimal with devices providing a higher
complete closure rate. 37
Our initial
experience with 51 patients treated with
different devices and a follow-up period of
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about 46.51 ± 43.43 years showed air
embolism in 2 cases (Figulla device) and
CVAs in 3 (5.9%) cases (Figulla device in 2
cases and DEVIE device in 1). This contrasts
favorably with the literature on the natural
course of patients with PFOs and cryptogenic
stroke. 38
In light of the results of our study, it
can be concluded that the most frequently
used device in the patients undergoing
surgery and PFO closure was the
AMPLATZER Occluder.
PFO closure with the AMPLATZER
Occluder device has been reported to be
associated with a low risk of device thrombus
formation compared to the other PFO
occluding devices. 39
We found no thrombus
formation at the AMPLATZER Occluder
device location or the other devices. In an
investigation, an 88% success rate for PFO
closure with the AMPLATZER Occluder
device at 6 months’ follow-up and 93% after
a mean follow-up of 18 months was
demonstrated, compared to 86.1% at 6
months and 86.7 at 24 months in the
CLOSURE I study, which used the
STARFlex device in another study. 20
In our
investigation, vis-à-vis residual shunts, a
successes rate of 79.48% was observed during
48 hours of follow-up after PFO closure. We
did not evaluate the success rates at 6 months
and 24 months. On the other hand, out of the
39 patients who underwent follow-up
echocardiography, 8 cases had residual shunts
(Figulla device in 5 patients and the
AMPLATZER Occluder device in 3). In
regard to the use of these 2 kinds of device in
those patients, the differences were not
significant. The AMPLATZER Occluder
device was modified for PFO indication and
was initially implanted on September 10,
1997 by the author in the presence of Kurt
Amplatzer, the inventor. Similar to all
AMPLATZER Occluder devices, it consists
of a nitinol mesh double disk containing
polyester fabric inside the 2 disks. Three sizes
of AMPLATZER PFO closure devices are
available and named after the diameter of the
right-sided disk. The most commonly used is
the 25-mm AMPLATZER PFO Occluder,
which features a right-sided disk (25 mm in
diameter) and a left-sided disk (18 mm in
diameter). The 18-mm AMPLATZER PFO
Occluder device comprises two 18-mm disks
and is meant for small PFOs with a stable
septum primum. The 35-mm AMPLATZER
PFO Occluder device is designed for large
PFOs with an extremely redundant and flimsy
septum primum atrial septum aneurysm and
features a 35-mm disk on the right side and a
28-mm disk on the left side. It requires a 9-Fr
sheath in contrast to the 2 smaller devices
fitting through an 8-Fr sheath. The most
widely used devices so far for PFO closure
are the CardioSEAL device (the only device
available in the USA between 2000 and 2002)
and the AMPLATZER PFO Occluder in the
rest of the world and available in the USA
since 2002. 39
In our study, the AMPLATZER
Occluder device was implanted in 12 (23.5%)
cases and the Cardi-O-Fix device in 4
(7.84%) patients, but the device implanted the
most was the Figulla, which was seen in 28
(54.90%) cases. According to our study, it can
be concluded that larger sizes of a PFO and
also of label devices such as the DEVIE may
lead to more complications. A PFO was
defined as TEE evidence of infused
microbubbles in the left atrium within 3
cardiac cycles after their appearance in the
RA, at rest or during the Valsalva release. The
shunt size was graded on a standard scale, 8, 9
with grade 0 indicating no microbubbles;
grade 1, 1 to 9 microbubbles; grade 2, 10 to
20 microbubbles; and grade 3, > 20
microbubbles. The complete closure of the
PFO was defined as a shunt grade of 0 and
effective closure as a shunt grade of 0 or 1. 39
A previous analysis to determine the potential
heterogeneity of the treatment effects
according to baseline covariates suggested
that closure might provide a greater benefit in
patients with a substantial grade 3 right-to-left
shunt and in those with an atrial septal
aneurysm. 39
The implantation of the
AMPLATZER PFO Occluder was associated
with a high rate of procedural success
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(96.1%), with minimal or no residual shunting
in 93.5% of the treated patients in a previous
study. 24
In our study, the success rate on the
basis of a residual shunt grade 0 was 79.48%,
which chimes in with the result of the other
similar studies. In our study, only 4 (7.84%)
long-term complications were reported: 1
(1.96%) patient undergoing open heart
surgery and PFO closure and 3 (5.88%) cases
with recurrent CVAs.
In our study, the DEVIE device was used only
in a 31-year-old man without any history of
cardiac risk factors and with a PFO size of 8
mm; he had no residual shunting on follow-up
echocardiography. After DEVIE implantation,
the patient had transient atrial fibrillation,
which was resolved spontaneously. Atrial
fibrillation occurrence in this patient may
have been due to a larger PFO size or the
performance of the device, which are less
prevalent. Consequently, larger studies with
greater sample sizes are required. According
to an investigation, no shunts were detected
by TTE in the long-term follow-up. 36
In the
present study, 39 patients were followed up
via echocardiography during a 48-hour period
following PFO closure. Of the 39 patients, 8
cases had residual shunts. Among the patients
with CVAs, 2 cases had no residual shunts
and 1 case had no follow-up
echocardiography. Nevertheless, 1 patient
with open heart surgery had residual shunts
on follow-up echocardiography.
CONCLUSIONS
In this long-term follow-up study,
percutaneous PFO closure was associated
with a low risk of recurrent stroke. No
mortality related to cerebrovascular or
cardiovascular diseases was found. There
were only a few short- or long-term device-
related complications. Accordingly,
percutaneous PFO closure is a safe and
efficient treatment option. Nonetheless, our
sample size is too small and long-term
randomized trials are needed to determine the
efficacy of different therapeutic measures and
the importance of patient selection.
Study Limitations
In our study, only 10 cases had recurrent
cerebrovascular events before PFO closure
and 41 patients underwent PFO closure after
the 1st embolic event. Our study evaluated
only 10 (20%) of the recurrent cases. One of
the salient limitations of the current study
might be related to incomplete or no follow-
up of some cases. Further studies with greater
sample sizes and comprehensive follow-up
times are recommended. The evaluation of
cryptogenic stroke was performed only by
neurologists and cardiologists, who referred
the patients with cryptogenic stroke and PFOs
together: This might have biased the case
selection. In this study, not all the patients
underwent follow-up echocardiography:
comprehensive echocardiography is required
to diagnose residual shunts at follow-up.
Finally, it was hard to diagnose cryptogenic
TIA or CVA in the patients.
ACKNOWLEDGEMENTS
We thank Dr Mona Heidarali for her scientific
writing and also Dr Homman Bakhshandeh
for his assistance with methodological
consultation. Also, we would like to
appreciate the support of the staff of the
Intervention Research Center at Rajaie
Cardiovascular, Medical, and Research
Center.
This project was financially supported by
the fund granted by Iran University of
Medical Sciences, Tehran, Iran.
There is no conflict of interest.
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Relationship Between Pulmonary Artery Pressure and the Occurrence of Atrial Fibrillation After CABG Beikmohammadi S, et al.
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Original Article Relationship Between Pulmonary Artery Pressure and the Occurrence of Atrial Fibrillation After CABG Beikmohammadi S, et al.
Relationship Between the Pulmonary Artery Pressure and
the Occurrence of Atrial Fibrillation After
Coronary Artery Bypass Graft Surgery
Somayeh Beikmohammadi1, MD; Hamid Reza Sanati
2, MD;
Mohammad Mehdi Peighambari*2, MD; Mohammad Mostafa Ansari-Ramandi
1, MD;
Mehrdad Azimi1, MD; Ali Zahedmehr
2, MD; Ata Firouzi
2, MD;
Reza Kiani2, MD; Farshad Shakerian
2, MD; Omid Shafe
2, MD
ABSTRACT
Background: Atrial fibrillation (AF) is one of the most common complications after cardiac
surgeries. The incidence of postoperative AF has risen continuously over the past decades.
AF is associated with lengthened hospital stays and risk of stroke. We sought to study the
relationship between the pulmonary artery pressure (PAP) and the occurrence of AF after
coronary artery bypass graft surgery (CABG).
Methods: This prospective observational study was designed to assess the relationship between the
PAP and the occurrence of post-CABG AF. Patients with chronic and paroxysmal AF before
surgery were excluded. All the patients had complete evaluation via echocardiography,
ECG, and laboratory testing. The patients were monitored for 3 days after surgery, and any
tachycardia monitored as AF was noted. The study population was divided into 2 groups:
with postoperative AF and without AF.
Results: We selected 232 patients, 106 with AF and 126 with sinus rhythm. The results confirmed
that the occurrence rate of AF after CABG was higher in the older patients (P ≤ 0.001). Both
univariate and multivariate analyses showed a significant relationship between a higher
occurrence rate of post-CABG AF and a higher PAP (mean value = 26.5 vs 20 mm Hg) in
the patients (P ≤0.001 and P = 0.01, respectively).
Conclusions: Although age has been the most important predictor for the occurrence of AF after
CABG in the past and present studies, there are many other variables affecting its
occurrence. Among the variables evaluated in this study, a higher PAP was a significant
predictor for a higher occurrence rate of AF following CABG. (Iranian Heart Journal
2017; 17(4): 17-20)
Keywords: Pulmonary artery pressure● Atrial fibrillation● Coronary artery bypass graft surgery
1 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, IR. Iran. 2 Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,
IR. Iran.
*Corresponding Author: Mohammad Mehdi Peighambari, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical
Sciences, Tehran, IR. Iran. E-mail: [email protected] Tel: 02123922128
Received: May 30, 2016 Accepted: August 14, 2016
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Relationship Between Pulmonary Artery Pressure and the Occurrence of Atrial Fibrillation After CABG Beikmohammadi S, et al.
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trial fibrillation (AF) occurs in about
20%–40% of patients after coronary
artery bypass graft surgery (CABG). 1-2
It is one of the most common complications
after cardiac surgeries. The incidence of
postoperative AF has increased continuously
over the past decades, possibly due to the
aging of the population undergoing cardiac
surgeries. 3
Postoperative AF usually occurs within 2–4
days after the procedure. Although generally
well tolerated, AF can also be life-
threatening—especially in the elderly and
patients suffering from left ventricular
dysfunction. 4 It is also associated with an
increased risk of thromboembolic events and
stroke 7 and ventricular dysrhythmias, as well
as lengthened hospital stays and resultant
extra costs.
Several studies seeking to predict the factors
that affect the occurrence of AF after CABG
have shown a consistent association between
increasing age and the risk of AF after
CABG. 1, 2,
6 Left atrial enlargement has also
been identified as an independent factor for
the high occurrence rate of AF following
CABG. 8 On the other hand, there have been a
few studies that have shown no relationship
between left atrial enlargement and the risk of
post-CABG AF. 2,9,10
In the previous studies,
the pulmonary artery pressure (PAP) has not
been studied as a factor affecting the
occurrence of AF post CABG.
The present study was designed to evaluate
the relationship between the PAP and the
occurrence of AF following CABG.
Perioperative data and variables were also
analyzed to assess which patients were at a
higher risk for developing post-CABG AF.
METHODS
This prospective observational study,
conducted from March 2013 until March
2016, sought to assess the relationship
between the PAP and the occurrence of post-
CABG AF. Patients with chronic AF before
surgery or a history of paroxysmal AF were
excluded from the study. Patients were
monitored continuously and examined during
the 1st 3 postoperative days in the intensive
care unit for having any form of tachycardia
compatible with AF and were selected
randomly and divided into 2 groups: with AF
and without AF. Rate control for the patients
was done using beta-blockers or calcium-
channel blockers and if resistant, intravenous
amiodarone was used. Before and after
surgery, all the patients had complete
paraclinical workup for electrolyte
disturbances, renal function tests, thyroid
function tests, lipid profile, and
echocardiographic evaluation of left
ventricular function, PAP, diastolic function,
and left atrial dimension.
Paraclinical Evaluation
Echocardiography was done for all the
patients with a Vivid 7 ultrasound system by a
single operator. Laboratory testing and
sample analysis were conducted using the
same laboratory kits.
Statistical Analysis
The data of the patients were recorded in
questionnaires. The collected data were then
analyzed using SPSS. The χ2
test and the
Student t-test were used to determine the
relationship between the different factors and
the occurrence of AF after CABG. The
differences between the 2 groups were
considered significant if they had a P value <
0.05. The univariate factors with a significant
difference were fed into a multivariate logistic
regression analysis to assess their independent
correlation with AF.
RESULTS
The demographic and paraclinical data of the
patients in the 2 groups are summarized in
Table 1.
The study population consisted of 232
patients, 106 of whom had AF and 126 sinus
A
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Relationship Between Pulmonary Artery Pressure and the Occurrence of Atrial Fibrillation After CABG Beikmohammadi S, et al.
19
rhythm. Only 2 patients underwent off-pump
CABG. None of the patients had CABG done
in an emergent condition. The 232 patients
comprised 46 female and 186 male
individuals. There was no significant
difference in the occurrence of AF between
the male and female genders. Our results also
demonstrated no significant difference
concerning the ejection fraction and left atrial
dimension between the 2 groups. Further, we
found no significant difference as regards the
renal and thyroid function tests between the 2
study groups. The 2 groups also did not
significantly differ vis-à-vis their electrolytes
and lipid profile. Also not significantly
different between the groups was the
prevalence of diabetes mellitus and
hypertension.
The patients who were older (mean age = 65
vs 60 y) had a significantly higher occurrence
rate of AF (P ≤ 0.001).
Both univariate and multivariate analyses
revealed a significant relationship between a
higher occurrence rate of AF following
CABG and a higher PAP (mean value = 26.5
vs 20 mm Hg) in the patients (P ≤ 0.001 and
P = 0.01, respectively).
Table 1. Demographic and paraclinical data of the patients studied by univariate analysis
P Mean Value and Range in the Non-AF Patients
Mean Value and Range in the AF Patients
<0.001 60 (53.75-65) 65 (58.75-70) Age (y)
0.063 74 (65-80) 75 (70-82.75) Weight (kg)
0.711 13.5 (12.375-14.9) 13.5 (12.4-14.55) Hemoglobin (g/dL)
0.394 39.75 (36-43) 38.95 (36.275-42) Hematocrit (%)
0.176 7300 (6000-8800) 7700 (6500-9000) White blood cells (/mL)
0.803 214.5 (181.5-265) 215 (179.75-258.5) Platelets (x109/L)
0.908 30 (20-40) 27.7 (24.75-40.25) C reactive protein (mg/L)
0.632 18 (14-20.25) 18 (13-22) Blood urea nitrogen (mg/dL)
0.631 0.9 (0.8-1) 0.85 (0.7-1) Creatinine (mg/dL)
0.975 77.5 (60.75-104.25) 79 (61-96) Low-density lipoprotein (mg/dL)
0.086 37.5 (35-45) 36.5 (33-43) High-density lipoprotein (mg/dL)
0.942 116 (80-154.5) 116.5 (77.75-162.5) Triglyceride (mg/dL)
0.259 1.2 (0.6-2) 1.1 (0.675-1.8) Thyroid-stimulating hormone (µIU/mL)
0.366 5 (4-6.05) 5.2 (4.4-6.625) Uric acid (mg/dL)
0.843 0.7 (0.475-1.2) 0.8 (0.475-6.625) Bilirubin (mg/dl)
0.849 0.01 (0.01-0.01) 0.01 (0-0.01) Troponin (ng/ml)
0.053 45 (33.75-50) 45 (35-55) Ejection fraction (%)
<0.001 20 (15-30) 26.5 (20-35) Pulmonary artery pressure (mm Hg)
0.493 3.4 (3.1-3.7) 3.4 (3.1-3.8) Left atrial diameter (cm)
0.042 141.5 (138.75-144) 140 (137-143) Sodium (mEq/L)
0.569 4.25 (4-4.5) 4.2 (4-4.5) Potassium (mEq/L)
0.056 2 2 Magnesium (mEq/L)
AF, Atrial fibrillation
DISCUSSION
The present study confirmed the higher
occurrence rate of AF after CABG in older
patients. It also showed that patients who had
a higher PAP were at an increased risk for
developing AF after CABG.
Similar to other studies, 8, 9
the present study
confirmed that aging is allied to a higher
occurrence rate of post-CABG AF. The
fibrosis and dilatation of the atria have been
shown to increase with age, 11
causing
consequent slowing in the conduction of the
atrial muscle fibers, which may be a possible
cause for the increase in the occurrence of
AF. 12
In the present study, both univariate and
multivariate analyses exhibited a significant
relationship between a higher PAP and the
occurrence of AF after CABG. Although the
clear mechanism is not known, patients with a
higher PAP also have more diastolic
dysfunction, which may be a contributing
factor for the occurrence of AF.
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Relationship Between Pulmonary Artery Pressure and the Occurrence of Atrial Fibrillation After CABG Beikmohammadi S, et al.
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There was no protective role for the
preoperative administration of beta-blockers
in our study, which was similar to the results
of a study done by Golmohammadi and Javid 13
in 2008.
Several findings in our study chime in with
the studies done before. Nonetheless, the
differences seen in the results of the stated
studies may be due to the different operative
procedures. The other aspects that may lead to
these discrepancies include differences in
patient characteristics and demographics
surveyed, sample size, number of risk factors
in the multivariate model, and monitoring
techniques.
ACKNOWLEDGEMENTS
None.
Financial Disclosure: No conflicts of interest
or financial interests are declared.
REFERENCES
1. Aranki SF, Shaw DP, Adams DH, Rizzo RJ,
Couper GS, VanderVliet M, Collins JJ Jr,
Cohn LH, Burstin HR. Predictors of atrial
fibrillation after coronary artery surgery:
current trends and impact on hospital
resources. Circulation. 1996; 94:390–397.
2. Mathew JP, Parks R, Savino JS, Friedman AS,
Koch C, Mangano DT, Browner WS, for the
Multicenter Study of Perioperative Ischaemia
Research Group. Atrial fibrillation following
coronary artery bypass graft surgery:
predictors, outcomes, and resource utilization.
JAMA. 1996; 276:300–306.
3. Creswell LL, Schuessler RB, Rosenbloom M,
Cox JL. Hazards of post-operative atrial
arrhythmias. Ann Thorac Surg 1993; 56:539–
49.
4. Wyse DG, Waldo AL, DiMarco JP, et al. A
comparison of rate control and rhythm control
in patients with atrial fibrillation. N Engl J
Med 2002; 347:1825–33.
5. Fuller JA, Adams GG, Buxton B. Atrial
fibrillation after coronary artery bypass
grafting. Is it a disorder of the elderly? J
Thorac Cardiovasc Surg 1989; 97:821–5.
6. Kowey PR, Dalessandro DA, Herbertson R,
Briggs B, Wertan MA, Rials SJ, Filart RA,
Marinchak RA. Effectiveness of digitalis with
or without acebutolol in preventing atrial
arrhythmias after coronary artery surgery. Am
J Cardiol. 1997; 79:1114–1117.
7. Mendes LA, Connelly GP, McKenney PA,
Podrid PJ, Cupples LA, Shemin RJ, Ryan TJ,
Davidoff R. Right coronary artery stenosis: an
independent predictor of atrial fibrillation
after coronary artery bypass surgery. Journal
of the American College of Cardiology. 1995
Jan 1; 25(1):198-202.
8. Ducceschi V, D'Andrea A, Liccardo B, Alfieri
A, Sarubbi B, De Feo M, Santangelo L,
Cotrufo M. Perioperative clinical predictors of
atrial fibrillation occurrence following
coronary artery surgery. European journal of
cardio-thoracic surgery. 1999 Oct 1;
16(4):435-9.
9. Zaman AG, Archbold RA, Helft G, Paul EA,
Curzen NP, Mills PG. Atrial fibrillation after
coronary artery bypass surgery a model for
preoperative risk stratification. Circulation.
2000 Mar 28; 101(12):1403-8.
10. Faggiano P, D’Aloia A, Zanelli E, Gualeni A,
Musatti P, Giordano A. Contribution of left
atrial pressure and dimension to signal-
averaged P-wave duration in patients with
chronic congestive heart failure. Am J Card
iol. 1997; 79:219–222.
11. Davies MJ, Pomerance A. Pathology of atrial
fibrillation in man. Br Heart J. 1972; 34:520–
525.
12. Spach MS, Dolber PC. Relating extracellular
potentials and their derivatives to anisotropic
propagation at a microscopic level in human
cardiac muscle: evidence for electrical
uncoupling of side-to- side fiber connections
with increasing age. Circ Res. 1986; 58:356–
371.
13. Golmohammadi M, Javid GE, Farajzadeh H.
Incidence and Risk Factors for Atrial
Fibrillation after First Coronary Artery Bypass
Grafting in Urumiyeh Imam Khomeini
Hospital from 2006 to 2008. International
Cardivascular Research Journal. 2010;4(2):86-
90.
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Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
21
Original Article Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
Effects of Primary PCI on Acute Inferior ST-Elevation
MI With Complete Heart Block
Vajihe Dorosti1, MD; Ata Firouzi
2*, MD;
Hossein Torabi Golsefid1, MD; Alireza Jebeli
1, MD
ABSTRACT
Background: Complete heart block is a common complication among patients with acute inferior
myocardial infarction (MI) and leads to increased mortality. The aim of this study was to
evaluate complete atrioventricular block after mechanical revascularization (primary
percutaneous coronary intervention [PCI]) in acute inferior MI.
Methods: This retrospective study enrolled 418 patients with acute inferior MI, who underwent
primary PCI in Rajaie Cardiovascular, Medical, and Research Center between 2011 and
2014. Thirty-eight (9%) patients had complete heart block. Three patients expired < 14 days
after PCI and were excluded from the study due to lack of follow-up. The restoration of the
sinus rhythm, need for permanent pacemaker (PPM) implantation, and heart-block recovery
time were compared between the other 35 patients.
Results: Among the 35 patients, the sinus rhythm was restored in 34 cases after a mean time of 50
hours. In 1 case, 14 days after primary PCI, PPM implantation was done due to the
persistence of the heart block. Neither the restoration of the sinus rhythm and nor PPM
implantation had a statistically significant correlation with primary PCI. Among the 34
patients, the heart-block recovery time was significantly longer (P < 0.05) in the diabetics
and in those with QRS > 120 ms in the initial ECG. This time was significantly shorter in
the patients undergoing successful stenting and the patients undergoing balloon angioplasty
and was very significantly shorter in the patients with a TIMI flow of 3 after
revascularization. In this study, the block recovery time was not correlated with the location
of the lesions in the coronary arteries, with thrombosuction, and with IIb/IIIa inhibitor
infusion. Age; gender; history of hypertension, dyslipidemia, and smoking; and very severe
left ventricular dysfunction did not have any effect on this time.
Conclusions: In light of the results of the current study, it can be concluded that mechanical
revascularization in patients with acute inferior MI complicated with complete heart block is
not effective on the restoration of the sinus rhythm and need for PPM implantation.
Nonetheless, the heart-block recovery time is significantly decreased and correlated with
successful stenting and balloon angioplasty. (Iranian Heart Journal 2017; 17(4): 21-25)
Keywords: Mechanical revascularization● Inferior MI● Complete heart block
1 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I. R. Iran. 2 Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,
I. R. Iran.
*Corresponding Author: Ata Firouzi, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I. R.
Iran.
E-mail: [email protected] Tel: 09126782019
Received: June 1, 2016 Accepted: September 20, 2016
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Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
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Pathophysiological and clinical studies have
recently shown that acute myocardial
infarction (MI) is one of the major causes of
atrioventricular (AV) conduction blocks.
Conductive defects are relatively common
after acute MI and play a role in survival.
Major conductive defects after MI include
1st-, 2nd- and 3rd-degree AV blocks and left
and right bundle branch blocks. Inferior wall
MI often results in heart block due to
perfusion defects in the supra-nodal or intra-
nodal parts and so presents mostly with 1st-
and 2nd-degree AV blocks, which are usually
transient and return to the normal sinus
rhythm spontaneously or pharmacologically
with the use of adenosine antagonists such as
methylxanthine in most patients.
Nevertheless, they sometimes progresses to
complete heart block due to the
hypoperfusion of the nodal artery and AV
nodal ischemia. 7 The incidence of complete
heart block, in turn, increases the mortality
rate and if not restored to the sinus rhythm in
the coming days, it requires permanent
pacemaker (PPM) implantation. This issue
increases the hospitalization course and costs
as well as complications following prolonged
hospitalization. The effects of coronary
revascularization on conduction blocks and
block durations after revascularization have
yet to be fully elucidated.
Therefore, in the present study, we surveyed
the effects of mechanical revascularization on
the resolution of heart blocks as well as the
block recovery time and need for PPM
implantation in patients with inferior MI. If
successful reperfusion has a significant
impact on heart block, we can choose the
most appropriate method for reperfusion and
reduce the need for PPM implantation,
hospitalization course, and complications
after PPM implantation.
METHODS
This cross-sectional study was performed in
Rajaie Cardiovascular, Medical, and Research
Center, Tehran, Iran. All patients with acute
inferior MI that underwent emergent
angiography and primary PCI between 2011
and 2014 were enrolled in the study. Patients
with inferior MI complicated with complete
heart block were selected for evaluation, and
their medical records were studied.
Patients with anterior or anterolateral acute
MI, positive history of previous AV blocks, or
PPM implantation as well as those who were
impossible to follow up were excluded.
A P value < 0.05 was considered the level of
significance in the statistical analyses.
Demographic data were obtained by
reviewing the hospital charts of the patients.
Acute inferior MI was diagnosed according to
the standard definition of inferior MI in the
inferior leads (II, III, and AVF) in the
standard 12-lead ECG. Angiographic findings
were collected. The presence of heart block
was determined according to ECG, and then
the effects of successful or unsuccessful
revascularization on heart block, block
recovery time, and final ECG were
investigated. SPSS, version 13, was used for
data analysis. The t-test and the χ2
test were
applied for the analyses.
RESULTS
Totally, 418 patients with acute inferior MI
were enrolled. Among them, 38 (9%) patients
had AV blocks. Three patients expired < 14
days after MI and were excluded owing to
lack of follow-up. Only 35 patients were
studied. The mean age of the patients was 60
years old. Also as regards age, 71.4% (n = 25)
of the patients were younger than 65 years old
and 28.6% (n = 10) were older than 65. In
terms of gender, 51.4% (n = 18) of the
patients were male and 48.6% (n = 17) were
female. In addition, 65.7% of the patients
were diabetic, 60% had hypertension, 45.7%
had dyslipidemia, and 34.3% were smokers
(Table 1).
Of the 35 patients, in 34 cases after a mean
time of 50 hours, the sinus rhythm was
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Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
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restored. The minimum block recovery time
was about 20 minutes, and the maximum time
was 216 hours. In 1 case, 14 days after
primary PCI, PPM implantation was done due
to the persistence of the heart block. In the 34
patients, the block recovery time was not
correlated with gender and age. In the diabetic
patients and in those with QRS > 120 ms in
the initial ECG, the block recovery time was
significantly longer (P < 0.05). Nonetheless, a
positive history of hypertension,
dyslipidemia, and smoking had no effect on
this time. With severe left ventricular
dysfunction, this time was slightly longer; the
difference, however, failed to constitute
statistical significance.
Of the 35 patients, 30 (85.7%) cases
successfully underwent stent placement
(successful primary PCI); in all these cases—
after a mean time of 34 hours—the sinus
rhythm was restored. In the other 5 (14.3%)
cases, due to lack of coronary blood flow with
a thrombolysis in myocardial infarction
(TIMI) flow of 3 after primary PCI (failed
PCI), stenting was not done. In these 5
patients, the block was resolved in 4 (80%)
cases after a mean time of 180 hours and 1
(20%) case was subjected to PPM
implantation due to the persistence of the
block after 14 days. The restoration of the
sinus rhythm and need for PPM implantation
were not correlated with successful primary
PCI (P = 0.143), whereas the mean block
recovery time had a significant correlation
with successful primary PCI (P = 0.01).
Additionally, 65% of the patients underwent
balloon angioplasty during revascularization,
so the block recovery time was significantly
shorter in them (P = 0.027). Thrombosuction
and IIb/IIIa inhibitor infusion had no
significant effect on the block recovery time.
The location of the lesion was in the distal
portion of the right coronary artery in 48.5%
of the patients, in the proximal portion of the
right coronary artery in 40%, and in the left
circumflex artery in 11.1%. There was no
significant correlation between the different
locations of the lesions and the block recovery
time.
Finally, after primary PCI, about 80% of the
patients had a TIMI flow of 3. The mean time
to the restoration of the sinus rhythm in these
patients was 24 hours, and the remaining 20%
of the patients had a TIMI flow < 3 with a
block recovery time of about 168 hours (P =
0.001).
Table 1. Heart-block recovery time based on the patients’ demographic data
Patients Number Percentage Block Recovery
Time (h) P
Age >65 y
<65 y 10 25
28.6 71.4
56 47
0.16
Gender male
female 18 17
51.4 48.6
58 41
0.70
DM diabetic
nondiabetic 23 12
65.7 34.3
67 17
0.049
HTN hypertensive
normotensive 21 14
60 40
67 24
0.22
DLP positive
negative 16 19
45.7 54.3
45 54
0.20
Smoking smoker
nonsmoker 12 23
34.3 65.7
39 57
0.08
LV dysfunction LVEF ≤35%
LVEF >35% 11 24
31.4 68.6
60 47
0.09
First QRS QRS >120
QRS <120 11 24
31.4 68.6
107 26
0.003
DM, Diabetes mellitus; HTN, Hypertension; DLP, Dyslipidemia; LV, Left ventricle; EF, Ejection fraction
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Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
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Table 2. Heart-block recovery time based on the treatment groups
Number Percent
age Block Recovery
Time (h) P
Thrombosuction yes
no 21 14
60 40
66 26
0.39
Balloon angioplasty yes
no 23 12
65 35
24 63
0.027
Stenting yes
no 30 5
85.7 14.3
34 180
0.01
IIb/IIIa I yes
no 19 16
54 45
44 56
0.67
Table 3. Heart-block recovery time based on the location of the lesions and the TIMI flow
Number Percentage
Block Recovery Time (h)
P
Primary PCI With stenting
w/o stenting 30 5
85.7 14.3
34 180
0.01
Location of lesion RCA distal
RCA proximal LCX
17 14 4
48.5 40 11.5
72 33 16.5
0.62
TIMI flow =3
<3 28 7
80 20
24 168
0.001
TIMI, Thrombolysis in myocardial infarction; PCI, Percutaneous coronary intervention; RCA, Right coronary artery; LCx, Left circumflex artery
DISCUSSION
We showed that the incidence of complete
heart block in patients with acute inferior MI
in our center was less than that reported in
previous studies (9% vs 25%). 1,4
There was no correlation between successful
reperfusion and heart-block recovery. Even in
the absence of successful reperfusion, in 80%
of the cases, the block resolved itself with the
passage of a longer time, and
revascularization did not reduce the rate of
PPM implantation in the patients.
There was a significant correlation between
successful reperfusion and the block recovery
time. The patients who had successful PCI
entirely returned to the sinus rhythm within
34 hours after PCI, while in the patients with
failed PCI, this time was 180 hours. Our
results also demonstrated that in the patients
with diabetes and in those with wide
complexes of QRS in the initial ECG, the
block recovery time was longer and
statistically significant. In our patients with
diabetes, this finding may have been due to
microvascular disease and in our patients with
wide QRS, due to the severity and extent of
infarction. This time was longer in the
patients with severe left ventricular
dysfunction and hypertension; the difference,
however, did not constitute statistical
significance. The block recovery time did not
show any difference between the male and
female patients, between the patients aged >
65 years and those aged < 65 years, and
between the smokers and the patients with
dyslipidemia and those without these risk
factors.
Considering the considerable impact of heart
block (especially high-grade AV block) on
the prognosis of acute inferior MI, any help to
improve this complication might mean a great
deal for the outcome. The restoration of the
sinus rhythm in our study tallied with that in a
study by Lee et al, 3 who reported that all their
patients had experienced the return of the
sinus rhythm after successful PCI. Our
results are similar to those reported by Sadr-
Ameli et al 7 in that both studies showed that
after successful PCI, the block recovery time
will be much shorter.
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Effects of Primary PCI on Acute Inferior ST-Elevation MI With Complete Heart Block Dorosti V, et al.
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CONCLUSIONS
According to the results of our study and
considering the results of the previous
observations, it can be concluded that
mechanical revascularization with successful
stent placement for patients suffering from
inferior MI with complete AV block
significantly reduces the block recovery time.
However, compared with no stenting, in terms
of the restoration of the sinus rhythm and the
reduction in the need for PPM implantation, it
was not effective.
ACKNOWLEDGEMENTS
None.
REFERENCES
1. Pirzada AM, Zaman KS, Mahmood K,
Sagheer T, Mahar SA, Jafri MH. High degree
Atrioventricular block in patients with acute
inferior Myocardial Infarction with and
without Right Ventricular involvement. J Coll.
Physicians Surg. Pak. 2009 May;19(5):269-74
2. Berger PB, Ruocco NA, RyanTJ, Frederick
MM, Jacobs AK, Faxon DP. Incidence and
prognostic implications of heart block
complicating inferior myocardial infarction
treated with thrombolytic therapy: results
from TIMI II. Journal of the American
College of Cardiology. 1992; 20(3):533-40.
3. Lee SN, Hwang YM, Kim GH, Kim JH, Yoo
KD, Kim CM, et al. Primary percutaneous
coronary intervention ameliorates complete
atrioventricular block complicating acute
inferior myocardial infarction. Clin Interv
Aging. 2014 Nov 24;9:2027-31.
4. Hwang YM, Kim CM, Moon KW.
Periprocedural temporary pacing in primary
percutaneous coronary intervention for
patients with acute inferior myocardial
infarction. Clin Interv Aging. 2016 Mar
10;11:287-92.
5. Berger PB, Ruocco NA Jr, Ryan TJ, Frederick
MM, Jacobs AK, Faxon DP. Incidence and
prognostic implications of heart block
complicating inferior myocardial infarction
treated with thrombolytic therapy: results
from TIMI II. J Am Coll Cardiol. 1992
Sep;20(3):533-40.
6. Giglioli C, Margheri M, Valente S, Comeglio
M, Lazzeri C, Chechi T, et al. Timing, setting
and incidence of cardiovascular complications
in patients with acute myocardial infarction
submitted to primary percutaneous coronary
intervention. Can J Cardiol. 2006
Oct;22(12):1047-52.
7. M. Sadr-Ameli MD, et al. "Heart Block
Recovery after Revascularization of Inferior
Myocardial Infarction." OFFICIAL
PUBLICATION OF THE IRANIAN HEART
ASSOCIATION: 26.
8. Sandra Gómez-Talavera, et al. Prognostic
implications of atrio-ventricular block in
patients undergoing primary coronary
angioplasty in the stent era. Acute Cardiac
Care, March 2014; 16(1): 1–8
9. Cosme García García, et al. Duration of
Complete Atrioventricular Block
Complicating Inferior Wall Infarction Treated
with Fibrinolysis, Rev Esp Cardiol.
2005;58(1):20-6
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A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in RHC: 7 Years’ Experience Sadr-Ameli M A, et al.
26
Original Article A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in RHC: 7 Years’ Experience Sadr-Ameli M A, et al.
A Survey on Mechanical Prosthetic Pulmonary Valve Replacement
in Rajaie Cardiovascular, Medical, and Research Center:7 Years’
Experience
Mohammad Ali Sadr-Ameli1, MD; Tahereh Zandi Kermanshahi
2, MD;
Mohammad Mehdi Peyghambari1, MD; Mandana Amir Sardari
3, MD;
Hooman Bakhshandeh3, MD; Maryam Shojaeifard
4, MD; Masoomeh Fooladi*
3, MD;
Maryam Moradian3, MD
ABSTRACT
Background: The present study aimed to assess the postoperative consequences and clinical course
after mechanical prosthetic pulmonary valve replacement (PVR) in patients candidated for
this procedure.
Methods: In a retrospective study, by referring and reviewing surgical reports at Rajaie
Cardiovascular, Medical, and Research Center, between 2006 and 2013, patients’
characteristics were assessed. Eligible patients were those who underwent PVR because of
significant pulmonary insufficiency, and postoperative consequences and clinical courses
were assessed retrospectively.
Results: In total, 415 patients underwent PVR. The most common underlying etiology was
tetralogy of Fallot, with a prevalence of 88.9%, followed by concomitant pulmonary
stenosis, with a prevalence of 11.1%. Only 1.5% of the patients had malfunction in their
mechanical prostheses. During the follow-up, no death was reported. Regarding the clinical
course of the disease after surgery, 3.1% of the patients suffered hemorrhagic events. None
of the patients developed thromboembolic events. The 1-, 2-, and 3-year hemorrhagic-free
survival rates were 98.9%, 98.4%, and 97.2%, respectively.
Conclusions: Regardless of the occurrence of postprocedural malfunction, PVR had an appropriate
midterm outcome with rare mortality and morbidity among our study population. Our study
showed that an appropriate anticoagulation support was able to confer a proper outcome vis-
à-vis thromboembolic or hemorrhagic events. (Iranian Heart Journal 2017; 17(4): 26-29)
Keywords: Prosthetic● Pulmonic valve● Mechanical
1 Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Department of Anesthesiology, Modares General Hospital, Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran. 3 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 4 Echocardiography Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.
*Corresponding Author: Masoomeh Fooladi, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.
E-mail: [email protected] Tel: 09126223176
Received: June 1, 2016 Accepted: October 10, 2016
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A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in RHC: 7 Years’ Experience Sadr-Ameli M A, et al.
27
ulmonary valve regurgitation refers to a
retrograde flow from the pulmonary
artery into the right ventricle during
diastole. Although mild physiological
regurgitation in this valve may be detected in
most healthy individuals, particularly in those
with advanced age, pathologic conditions
leading to the production of excessive and
clinically significant regurgitation can result
in the impairment of right ventricular function
and eventual clinical manifestations of right-
sided volume overload and heart failure. 1,2
The incompetence of the pulmonic valve can
occur in consequence of some major
pathological processes, including dilatation of
the pulmonic valve ring, acquired alteration in
the morphology of the pulmonic valve leaflet,
and congenital absence or malformation of the
valve. 3 These conditions frequently appear in
some underlying etiologies such as primary
and pulmonary hypertension, tetralogy of
Fallot, infective endocarditis, rheumatic heart
disease, carcinoid tumors, and some
medications or complications related to the
therapeutic balloon catheter dilatation of a
stenotic pulmonic valve. 4
Pulmonic regurgitation is seldom severe
enough to warrant special treatment except
only for controlling symptoms of heart failure
or pulmonary hypertension. 5, 6
In this regard,
the surgical reconstruction or replacement of
the pulmonic valve, preferably with a
bioprosthetic valve, is the appropriate option. 7 More recently, percutaneous intervention for
dysfunctional right ventricular outflow tract
conduits has become available. 8 The
intermediate-term results have shown that
percutaneous bioprosthetic valve implantation
is a reasonable option for patients with
dysfunctional right ventricular outflow tract
conduits, especially those with a high surgical
risk. 9 Freedom from valve dysfunction or
reintervention following percutaneous
bioprosthetic valve placement has been
reported to be 93.5% at 1 year. 10
In this
regard, periodic echocardiographic
reassessments can provide a longitudinal
comparison of the progression of both
regurgitation and right ventricular size and
function following pulmonary valve
replacement (PVR). 11
The present study aimed to assess the
postoperative consequences and clinical
courses after mechanical prosthetic PVR in
patients candidated for this procedure.
METHODS
In a retrospective study, by referring and
reviewing surgical reports at Rajaie
Cardiovascular, Medical, and Research
Center, between 2006 and 2013, the patients’
baseline characteristics, cardiovascular risk
factors, preoperative and postoperative
laboratory and echocardiography assessments,
and preoperative medications were assessed.
Eligible patients were those who underwent
PVR because of significant pulmonary
insufficiency. The results of the statistical
analyses are presented as means ± SDs for the
quantitative variables and summarized as
absolute frequencies and percentages for the
categorical variables. The normality of the
data was analyzed using the Kolmogorov–
Smirnoff test. The categorical variables were
compared using the χ2
test or the Fisher exact
test when > 20% of cells with an expected
count < 5 were observed. The quantitative
variables were also compared via the
ANOVA or the Wallis H-test. The
complication-free survival rate was assessed
using the Kaplan–Mayer survival analysis.
For the statistical analyses, SPSS—version
16.0 for Windows (SPSS Inc., Chicago, IL)—
was used. A P value ≤ 0.05 was considered
statistically significant.
RESULTS
Baseline Characteristics
In total, 415 patients underwent PVR. The
mean age of the patients was 27.65 ± 8.50
years. The most common underlying etiology
for PVR was tetralogy of Fallot with a
prevalence of 88.9%, followed by
concomitant pulmonary stenosis, with a
prevalence of 11.1%. With respect to the type
P
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A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in RHC: 7 Years’ Experience Sadr-Ameli M A, et al.
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of the implanted valves, the most frequently
applied valves were the St Jude (88%) and the
CarboMedics (n= 19). In the last clinical visit,
28.6% of the subjects with valvular
malfunction and 86.9% of those without
malfunction remained asymptomatic (P <
0.001); however, cardiac arrhythmia occurred
in 9%, chest pain in 2%, dyspnea in 36.5% ,
and endocarditis in 3.2%—indicating a
significant discrepancy in the prevalence of
dyspnea as the dominant clinical symptom (P
< 0.001) (Fig. 1). Apropos the clinical course
of the disease after surgery, 3.1% of the study
population suffered hemorrhagic events. None
of the patients experienced thromboembolic
events. The 1-, 2-, and 3-year hemorrhagic-
free survival rates were 98.9%, 98.4%, and
97.2%, respectively (Fig. 2).
Figure 1. Prevalence of the symptoms in the study
population in terms of valvular malfunction.
Figure 2. Kaplan–Meier plot shows the probability of
hemorrhage-free survival in the patients.
DISCUSSION
The present study is the 1st study to compare
the midterm outcome of the surgical
management of pulmonary valve
insufficiency between patients. First and
foremost among our results is that an
appropriate postoperative outcome in terms of
survival as well as lack of complications such
as thromboembolic or hemorrhagic events can
be expected following mechanical PVR. Until
now, the implantation of mechanical
pulmonary valves has not been routinely
recommended, except when there are some
indications, because of the evidence of
pulmonary thromboembolic events. 12
Our
findings showed that there were no deaths or
thromboembolic events at midterm follow-up.
We also achieved a high hemorrhagic-free
survival rate as well as no significant change
in the international normalized ratio (INR)
values within the follow-up period in the
treated patients, indicating a proper
anticoagulation management of the affected
patients. In sum, surgical intervention as PVR
can be the 1st and final choice for treating
pulmonary insufficiency regardless of the
type of the underlying etiology and the
likelihood of postoperative valvular
malfunction.
A review of the literature underscores similar
findings with respect to a proper
postoperative outcome. Deorsola et al 13
reported that all their patients remained
asymptomatic during an 11-year follow-up
period, with no arrhythmias and with good
anticoagulation. In a study by Tjalling et al, 14
mechanical PVR had promising early
midterm results.
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A Survey on Mechanical Prosthetic Pulmonary Valve Replacement in RHC: 7 Years’ Experience Sadr-Ameli M A, et al.
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In total, it seems that regardless of the
occurrence of postprocedural malfunction,
PVR has an appropriate midterm outcome,
with rare mortality and morbidity. Our study
showed that an appropriate anticoagulation
support was able to confer a proper outcome
with regard to thromboembolic or
hemorrhagic events.
REFERENCES
1. Bonow RO, Carabello BA, Chatterjee K, et
al. 2008 Focused update incorporated into the
ACC/AHA 2006 guidelines for the
management of patients with valvular heart
disease: a report of the American College of
Cardiology/American Heart Association Task
Force on Practice Guidelines (Writing
Committee to Develop Guidelines for the
Management of Patients With Valvular Heart
Disease). Circulation2008;118:e523-
e661 [PubMed]
2. Nishimura RA, Otto CM, Bonow RO,
Carabello BA, Erwin JP 3rd, Guyton RA, et
al. 2014 AHA/ACC guideline for the
management of patients with valvular heart
disease: executive summary: a report of the
American College of Cardiology/American
Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol. 2014 Jun 10.
63(22):2438-88.
3. Chaturvedi, Rajiv R; Redington, Andrew N
(2007-07-01). "Pulmonary regurgitation in
congenital heart disease". Heart 93 (7): 880–
889.
4. Discigil B, Dearani JA, Puga FJ, et al. Late
pulmonary valve replacement after repair of
tetralogy of Fallot. J Thorac Cardiovasc Surg
2001;121:344–51.
5. Otto CM, Bonow RO. Valvular heart disease.
In: Libby P, Bonow RO, Mann DL, Zipes DP,
editors. , eds.Braunwald's Heart Disease: A
Textbook of Cardiovascular Medicine 8th
ed.Philadelphia, PA: WB Saunders;
2007:1625-1712
6. Bouzas B, Kilner PJ, Gatzoulis MA.
Pulmonary regurgitation: not a benign
lesion. Eur Heart J.2005;26:433–439.
7. Cheung EW, Wong WH, Cheung YF. Meta-
analysis of pulmonary valve replacement after
operative repair of tetralogy of fallot. Am J
Cardiol. 2010;106:552–557.
8. Ho JG1, Schamberger MS, Hurwitz
RA, Johnson TR, Sterrett LE, Ebenroth ES.
The Effects of Pulmonary Valve Replacement
for Severe Pulmonary Regurgitation on
Exercise Capacity and Cardiac Function.
Pediatr Cardiol. 2015 Aug;36(6):1194-203.
doi: 10.1007/s00246-015-1143-3. Epub 2015
Mar 10.
9. Lee C1. Surgical management of
chronic pulmonary regurgitation after relief of
right ventricular outflow tract obstruction.
Korean Circ J. 2012 Jan;42(1):1-7. doi:
10.4070/kcj.2012.42.1.1. Epub 2012 Jan 31.
10. McElhinney DB, Hellenbrand WE, Zahn EM,
Jones TK, Cheatham JP, Lock JE, et al. Short-
and Medium-Term Outcomes After
Transcatheter Pulmonary Valve Placement in
the Expanded Multicenter US Melody Valve
Trial. Circulation. 2010 Aug 3. 122(5):507-
16. [Medline].
11. Dodo H, Perloff JK, Child JS, et al. Are high-
velocity tricuspid and pulmonary regurgitation
endocarditis risk substrates?. Am Heart J.
1998 Jul. 136(1):109-14. [Medline].
12. Schreiber C, Horer J, Kostolny M, Holper K,
Lange R. Is there a role for mechanical valved
conduits in the pulmonary position? Ann
Thorac Surg 2005;79(5):1662—7 [discussion
1667—8]
13. Deorsola L1, Abbruzzese PA, Aidala E,
Cascarano MT, Longo S, Valori A, Ochieng
GA. Pulmonary valve replacement with
mechanical prosthesis: long-term results in 4
patients. Ann Thorac Surg. 2010
Jun;89(6):2036-8. doi:
10.1016/j.athoracsur.2009.10.012.
14. Tjalling W. Waterbolk, Elke S. Hoendermis,
Inez J. den Hamer, Tjark Ebels. Pulmonary
valve replacement with a mechanical
prosthesis.Promising results of 28 procedures
in patients with congenital heart disease :
European Journal of Cardio-thoracic Surgery.
30 (2006) 28—34
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Postoperative Outcome of Transcatheter Closure of Atrial Septal Defects using the AMPLATZER Septal Occluder Nasiri Brojeni M, et al.
30
Original Article Postoperative Outcome of Transcatheter Closure of Atrial Septal Defects using the AMPLATZER Septal Occluder Nasiri Brojeni M, et al.
Postoperative Outcome of the Transcatheter Closure of Atrial Septal
Defects Using the AMPLATZER Septal Occluder
Marzieh Nasiri Brojeni1, MD; Parisa Seilani
1, MD;
Mozhgan Parsaee*2, MD; Sedigheh Saedi
1, MD
ABSTRACT
Background: The AMPLATZER Septal Occluder (ASO) has successfully replaced surgery for the
repair of atrial septal defects (ASDs) within the last decade. However, the outcome and
clinical consequences of this procedure have not been fully assessed. Hence, the present
study aimed to determine the results of the application of the ASO in the nonsurgical
transcatheter closure of ASDs.
Methods: Forty-seven consecutive patients were assessed via transesophageal echocardiography to
determine secundum ASDs. The study end points were the assessment of the
echocardiographic consequences of ASD closure using the ASO and also the determination
of the presence of postoperative complications. The patients were reassessed via
transthoracic echocardiography 1 day, 1 month, and also 6 months after the intervention.
Results: An assessment of the trend of the changes in right ventricular dimension and functional
status showed a significant decrease in right ventricular size as well as improvement in
function within 6 months after ASD closure using the ASO. The mean pulmonary artery
pressure was also significantly decreased. Unsuccessful ASD closure was detected in only 3
patients, with an overall failure rate of 6.4%. Regarding postoperative complications, device
displacement was found in 2.1%, interatrial septum rupture in 12.8%, small pericardial
effusion in 12.8%, tamponade in 2.1%, and small residual ASDs in 12.8%, all of which were
resolved procedurally within the following month.
Conclusions: The clinical efficacy of the nonsurgical transcatheter closure of ASDs with the ASO
was underlined in our experiment, indicating that it is a good and standard alternative to
surgical repair. (Iranian Heart Journal 2017; 17(4): 30-35)
Keywords: Atrial septal defect (ASD) ● ASD occluder ● RV enlargement
1 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Echocardiography Research Center, Rajaie Cardiovascular Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.
*Corresponding Author: Mozhgan Parsaee, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences,
Tehran, I.R. Iran. E-mail: [email protected] Tel: 023922151
Received: June 19, 2016 Accepted: October 25, 2016
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trial septal defects (ASDs) account for
about 10% of all congenital heart
defects. Despite their benign nature,
ASDs can lead to morbidity and even
mortality if left untreated. 1,2
The closure of
secundum ASDs with percutaneous devices
was initially described by King et al in 1974.
Later, the safety and efficacy of various
devices were tested, which paved the way for
the eventual introduction of these devices as
proper alternatives to the surgical closure of
secundum ASDs. 3-5
In most developed and
even developing countries, the use of devices
for ASD closure has become the preferred
method. 6 Currently, the utilization of these
devices confers variable degrees of success
vis-à-vis ASD closure and minimization of
residual shunts. 7
In the past decade, the AMPLATZER Septal
Occluder (ASO) has successfully replaced
surgery for ASD closure, especially in adults,
so much so that it is now deemed the standard
method for the repair of secundum ASDs. 8,9
However, the outcome and clinical
consequences of this procedure have yet to be
fully elucidated. Hence, the present study
aimed to determine the results of the
application of the ASO in the nonsurgical
transcatheter closure of ASDs.
METHODS
This prospective interventional case series
was performed by the echocardiography and
coronary angiography centers at Rajaie
Cardiovascular, Medical, and Research
Center, Tehran, Iran, in 2015. The study end
points were the assessment of the
echocardiographic consequences of ASD
closure using the ASO and also the
determination of the presence of postoperative
complications with the size of the ASD, size
of the ASD margins, size of the device, and
also size of the balloon catheter. In total, 47
consecutive patients were assessed via
transesophageal echocardiography to
determine secundum ASDs, size of the ASD
margins, dimensions and function of the right
ventricle (RV), and also pulmonary artery
pressure (PAP). Patients with the ASD size <
4 cm; anterior size of the rim < 2 mm; and the
sizes of the anteroinferior rims, inferior vena
cava (IVC) rims, superior vena cava (SVC)
rims, and posterosuperior rims < 7 mm
underwent echocardiography-guided
catheterization for ASD closure. The patients
were reassessed via transthoracic
echocardiography 1 day, 1 month, and also 6
months after the intervention to assess
postoperative complications, including
pericardial effusion, tamponade, device
displacement, clot formation on device, atrial
tissue erosions, postoperative RV size and
function, and also PAP.
The results are reported as medians (1st and
3rd quartiles) for the quantitative variables
and percentages for the categorical variables.
The groups were compared using the Student
t-test for the continuous variables and the χ2
test (or the Fisher exact test, if required) for
the categorical variables. Changes in the
postoperative parameters were determined by
dividing the change between the baseline and
the final measurements by the duration of the
follow-up. A P value ≤ 0.05 was considered
statistically significant. All the statistical
analyses were performed using SPSS, version
16.0 (SPSS Inc., Chicago, IL, USA), and
SAS, version 9.1 for Windows (SAS Institute
Inc., Cary, NC, USA).
RESULTS
In total, 47 patients, candidated for ASD
closure with the ASO, were assessed. The
median age of the subjects was 32 (29, 43)
years, and 72.3% were female. The mean
ASD size was 17.4 mm, mean anteroinferior
rim size was 10.3 mm, mean posterosuperior
rim size was 10.2 mm, mean anterosuperior
rim size was 3.36 mm, and the mean
posteroinferior rim size was 11.2 mm. Also,
the mean SVC and IVC rim sizes were 11.7
mm and 12.7 mm, respectively. Regarding
RV size, none of the patients had a normal
size, while dilatation was mild in 4.3%, mild
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to moderate in 19.1%, moderate in 36.2%,
moderate to severe in 12.7%, and severe in
27.7%. Moreover, 48.9% of the study
population had a normal RV functional status,
while RV dysfunction was mild in 38.3%,
mild to moderate in 8.5%, and moderate in
the remaining 4.3%. An assessment of the
trend of the changes in RV dimension (Table
1) showed a significant decrease in RV size
within 6 months after ASD closure with the
ASO (P < 0.001). A normal RV size was
revealed in 44.7% of the patients 6 months
after the procedure. Similarly, RV function
was gradually improved within 6 months after
the procedure (P < 0.001) (Table 1). The
mean PAP at baseline was 28.98 ± 6.46 mm
Hg, which decreased to 27.57 ± 6.23 mm Hg
at 1 day and 25.79 ± 5.90 mm Hg at 6 months
after the procedure (P < 0.001). Apropos the
postoperative complications, 1 day after the
procedure, device displacement was detected
in 2.1% of the patients, interatrial septum
rupture in 12.8%, small pericardial effusion in
12.8%, tamponade in 2.1%, erosion on atrial
tissue in 0%, and small residual ASDs in
12.8%, all of which were resolved
procedurally within the following month. In
addition, unsuccessful ASD closure was
recorded in only 3 patients, with an overall
failure rate of 6.4%. Table 2 summarizes the
study indices between the groups with and
without pericardial effusion event, indicating
no difference between the 2 groups in terms
of the sizes of the ASDs, posterosuperior
rims, anterosuperior rims, anteroinferior rims,
posteroinferior rims, SVC and IVC rims,
balloons, and also the devices. Further, a
comparison of the aforementioned parameters
between the groups with and without residual
ASDs showed no difference in all the
parameters between the 2 groups (Table 3).
The present study could not find any
relationship between the presence of
pericardial effusion and the study parameters.
Table 1. Trend of the change in RV size and function after the procedure
Parameters Baseline 1 Day Later 1 Month Later 6 Months Later P
PAP (mm Hg) 28 27 25 25 < 0.001
RV size
Normal 0 (0%) 2 (4.3%) 10 (21.3%) 21 (44.7%) < 0.001
Mild 2 (4.3%) 9 (19.1%) 20 (42.6%) 20 (42.6%)
Mild to moderate 9 (19.1%) 11(23.4%) 12 (25.5%) 3 (6.4%)
Moderate 17 (36.2%) 15 (31.9%) 2 (4.3%) 0 (0%)
Moderate to severe 6 (12.7%) 4 (8.5%) 0 (0%) 0 (0%)
Severe 13 (27.7%) 3 (6.4%) 0 (0%) 0 (0%)
RV function
Normal 23 (48.9%) 24 (51.1%) 36 (76.6%) 41(87.2%)
< 0.001
Mild 18 (38.3%) 15 (31.9%) 5 (10%) 1 (2.1%)
Mild to moderate 4 (8.5%) 3 (6.4%) 3 (6.4%) 2 (4.3%)
Moderate 2 (4.3%) 2 (4.3%) 0 (0%) 0 (0%)
Moderate to severe 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Severe 0 (0%) 0 (0%) 0 (0%) 0 (0%)
RV, Right ventricle; PAP, Pulmonary artery pressure
Table 2. Comparison of the study parameters between the groups with and without PE events
Parameters Group With PE Group Without PE P
Size ASD mm 19 (13, 22) 15(13, 20) 0.493
Anteroinferior rim 10(5.75, 13.5) 10(8.7, 12.2) 0.828
Posterosuperior rim 9 (6.8, 16.2) 10(8, 12) 0.986
Anterosuperior rim 1 (0.5, 2) 2(0, 8) 0.472
Posteroinferior rim 16(10, 25) 10(6, 15) 0.84
SVC rim 11.5(6.5, 15) 11(10, 15) 0.677
IVC rim 14 (9.8, 21.2) 11(8, 16) 0.472
Sizing balloon 22(14, 24) 19(16, 22) 0.606
Device size 26(17, 26) 21(18, 25) 0.605
PE, Pericardial effusion; ASD, Atrial septal defect; SVC, Superior vena cava; IVC, Inferior vena cava
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Table 3. Comparison of the study parameters between the groups with and without residual ASDs
Parameters Group With Residual ASDs
Group Without Residual ASDs
P
Size ASD mm 15 (14, 24) 16 (13, 20) 0.514
Anterosuperior rim 12 (9.2, 13) 10(8, 12) 0.322
Posterosuperior rim 9.5 (7.5, 12) 10 (7.5, 12) 0.669
Anterosuperior rim 3.5 (0, 10) 2 (0, 5.2) 0.803
Posteroinferior rim 11.5 (5.2, 16.5) 10 (7, 15) 0.907
SVC rim 12.5 (9.5, 15) 10 (9, 14) 0.628
IVC rim 14.5 (8.7, 17) 11.7 (8, 16) 0.472
Sizing balloon 20 (17.1, 26) 19.5 (15.7, 22) 0.559
Device size 21 (18, 29) 21 (18, 26) 0.652
ASD, Atrial septal defect; SVC, Superior vena cava; IVC, Inferior vena cava
DISCUSSION
The clinical benefits of the catheter-based
closure of ASDs using the ASO have been
described in some recent studies. Almost all
these studies have emphasized the superiority
of this procedure for ASD closure in view of
its favorable outcomes and minimal
postoperative complications. In this regard,
our results similarly demonstrated the high
therapeutic effectiveness of the ASO
procedure in terms of its favorable outcome
and rare complications within a 6-month
follow-up period. The overall success rate of
the procedure in our experiment was 93.6%.
In fact, it seems that employing the ASO
technique can provide appropriate deployment
in the closure of large secundum ASDs. In a
study by Narin et al, 10
after adjusting for age
and body weight, the conventional method
was found 5.6 times more risky than the ASO
technique in terms of process failure.
Bartakian et al 11
showed that the procedural
success rate of the ASO was 100% with no
significant complication either during the
procedure or at 1 year’s follow-up, both in
transthoracic and transesophageal
echocardiographic assessments. In another
study by Abid et al, 12
the final success rate of
the procedure was 90.9% and 8.6% of the
patients developed complications including 2
cases of prosthesis migration and 1 case of
large residual shunting. The authors also
reported that 11.7% of their study population
needed to undergo surgery; however, no
major complications such as thromboembolic
events, obstruction of the intracardiac
structures, cardiac perforation, device
embolization, and endocarditis or death
occurred during the follow-up—which is
nearly similar to our observations. Behjati et
al 13
also assessed the outcome of the ASO
procedure in patients with ASDs and showed
complete closure in 96.2% of their patients—
with residual shunts in 3.8%, tamponade
requiring drainage in 1.7%, device
embolization to the left atrium and the RV
outflow tract in 3.4%, and late wire fracture in
1.7%. Likewise, Knepp et al 14
reported a
complete closure rate of 97% by using the
ASO procedure for removing secundum ASD
defects. The rare postoperative complications
in their study were chest pain,
supraventricular tachycardia, atrial
fibrillation, premature ventricular beats,
migraine, mild aortic insufficiency, and only
1 case of death. All the experiments
underscored the clinical efficacy of the ASO
procedure in closing secundum ASDs with a
success rate ranging from 89% to 100% as
well as with rare postoperative complications
and very rare long-term postoperative
mortality, emphasizing the high efficacy and
safety of the procedure as an acceptable
alternative to surgical approaches.
The ease of implantation and also the high
success rate of ASD closure with the ASO
have resulted in the widespread use of this
transcatheter ASD occlusion device in lieu of
routine surgical closure in several clinical
settings. 15-20
The aforementioned success rate
can be a result of the special design of the
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ASO. Firstly, the device’s waist between the
left and right retention discs is a stent, which
results in its self-centering within the defect:
This requires only a small rim around the
defect for firm cross-clamping with the
retention discs. Secondly, because it does not
require a large delivery system, the ASO can
be retrieved without damaging the device. 21
Thus, the ASO can be indicated for almost all
candidates.
REFERENCES
1. Campbell M. Natural history of atrial septal
defect. Br Heart J 1970;32:820–826.
2. Craig, RJ, Selzer, A. Natural history and
prognosis of atrial septal defect. Circulation
1968;37:805–815.
3. Du ZD, Hijazi ZM, Kleinman CS, Silverman
NH, Larntz K. Comparison between
transcatheter and surgical closure of
secundum atrial septal defect in children and
adults. J Am Coll Car- diol 2002;39:1836–
1844.
4. Nugent A, Britt A, Gauvreau K, Piercey G,
Lock J, Jenkins. De- vice closure rates of
simple atrial septal defects optimized by the
STARflex. J Am Coll Cardiol 2006;48:538–
544.
5. Jones TK, Latson LA, Zahn E, Fleishman CE,
Jacobson J, Vincent R, Kanter K. Multicenter
Pivotal Study of the HELEX Septal Occluder
Investigators. Results of the US multicenter
pivotal study of the HELEX septal occluder
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6. Everett AD, Jennings J, Sibinga E, Owada C,
Lim DS, Cheatham J, Holzer R, Ringewald J,
Bandisode R, Ringel R. Community use of the
amplatzer atrial septal defect occluder: Results
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study. Pediatr Cardiol 2009;30:240–247.
7. Kong X, Cao K, Xu D, Chen M, Yang R,
Huang J. Transcatheter closure of secundum
atrial septal defect with a new self-expanding
nitinol double disk device (Amplatzer device):
experience in Nanjing. J Interv Cardiol
2001;14:193-196.
8. Masura J, Gavora P, Podnar T. Long-term
outcome of transcatheter secundum-type
atrial septal defect closure using Amplatzer
septal occluders. J Am Coll Cardiol
2005;45:505-507.
9. Peters B, Ewert P, Schubert S, Abdul-Khaliq
H, Schmitt B, Nagdyman N, Berger F. Self-
fabricated fenestrated Amplatzer occluders
for transcatheter closure of atrial septal defect
in patients with left ventricular restriction:
midterm results. Clin Res Cardiol
2006;95:88-92.
10. Narin N1, Baykan A, Argun M, Ozyurt A,
Pamukcu O, Bayram A, Uzum K. New
modified balloon-assisted technique to
provide appropriate deployment in the closure
of large secundum atrial septal defect using
amplatzer septal occluder in children. J
Invasive Cardiol. 2014 Nov;26(11):597-602.
11. Bartakian S1, El-Said HG, Printz B, Moore
JW. Prospective randomized trial of
transthoracic echocardiography versus
transesophageal echocardiography for
assessment and guidance of transcatheter
closure of atrial septal defects in children
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12. Abid D, Rekik N, Mallek S, Abid L, Akrout
M, Smaoui M, Abdennadher M, Kolsi K,
Frikha I, Kammoun S. Percutaneous closure
of Ostium secundum atrial septal defect using
amplatzer occlusion device. Tunis Med. 2013
Jul;91(7):453-7.
13. Behjati M1, Rafiei M, Soltani MH, Emami M,
Dehghani M. Transcatheter closure of atrial
septal defect with amplatzer septal occluder in
adults: immediate, short, and intermediate-
term results. J Tehran Heart Cent. 2011
Spring;6(2):79-84. Epub 2011 May 31.
14. Knepp MD1, Rocchini AP, Lloyd TR,
Aiyagari RM. Long-term follow up of
secundum atrial septal defect closure with the
amplatzer septal occluder. Congenit Heart
Dis. 2010 Jan-Feb;5(1):32-7. doi:
10.1111/j.1747-0803.2009.00358.x.
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15. Chan KC, Godman MJ, Walsh K, et al.
Transcatheter closure of atrial septal defect
and interatrial communications with a new
self-expanding nitinol double disc device
(Amplatzer septal occluder): multicentre UK
experience. Heart 1999;82:300–6.
16. Moore JW, Norwood JB, Kashow KM, et al.
Closure of atrial septal defects in the cardiac
catheterization laboratory: early results using
the Amplatzer septal occlusion device. Del
Med J 1998;70:513–16.
17. Pfammatter JP, Friedli B, Oberhansli I, et al.
[Nonsurgical occlusion of an atrial septal
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Schweiz Rundsch Med Prax 2000;89:225–31.
18. Radhakrishnan S, Marwah A, Shrivastava S.
Nonsurgical closure of atrial septal defect
using the Amplatzer septal occluder in
children feasibility and early results. Indian
Pediatr 2000;37:1181–7.
19. Waight DJ, Koenig PR, Cao QL, et al.
Transcatheter closure of secundum atrial
septal defects using the Amplatzer septal
occluder: clinical experience and technical
considerations. Curr Intervent Cardiol Rep
2000;2:70–7.
20. Walsh KP, Maadi IM. The Amplatzer septal
occluder. Cardiol Young 2000;10:493–501.
21. Hausdorf G, Kaulitz R, Paul T, et al.
Transcatheter closure of atrial septal defect
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Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
36
Original Article Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
Effects of a Nursing Supportive Program on Anxiety and Stress
Levels in the Family Members of Patients After
Cardiac Surgery in the ICU
Tayebe Rezaei1, MS; Rasoul Azarfarin
2*, MD; Ziae Totonchi
1, MD;
Hooman Bakhshandeh 1, MD; Azin Alizadehasl
2, MD; Solmaz Fakhari
3, MD
ABSTRACT
Background: This research was conducted to investigate the effects of a nursing supportive
program on anxiety and stress levels in the family members of patients admitted to the
intensivee care unit (ICU) after cardiac surgery.
Methods: This research was a quasi-experimental study. A control group and an intervention group
(each = 35), both comprised of the family members of post-cardiac surgery patients
admitted to the ICU, were studied. The intervention group received a nursing supportive
program initially 2 hours after their patients entered the ICU (1st day) and thereafter on the
2nd and 3rd days. The control group received only the routine information. Demographic
variables and an adjusted Depression Anxiety Stress Scales (DASS-21) were used to assess
the anxiety and stress levels of the family members of the patients.
Results: Demographic variables and the DASS scores had no statistically significant differences in
stress levels between the 2 groups before the intervention. However, after the intervention,
the mean score of the stress level in the intervention group dropped significantly in
comparison with the control group (P = 0.0001). Anxiety levels in both groups were reduced
after the intervention. However, although a statistically significant difference was observed
between the 2 groups 2 hours after ICU admission and on the 2nd ICU day (P = 0.0001),
there was no significant difference on the 3rd ICU day (P = 0.993).
Conclusions: In light of the findings of the present study, our nursing supportive program, which
was aimed at providing information, emotional and mental support, and reassurances to the
family members of post-cardiac surgery patients hospitalized in the ICU, was able to
decrease their stress levels and to some extent their anxiety levels. (Iranian Heart Journal
2017; 17(4): 36-41)
Keywords: Family nursing● Stress● Anxiety● Critical care nursing
1 Rajaie Cardiovascular, Medical, and Research center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Echocardiography Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 3 Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, I.R. Iran.
*Corresponding Author: Rasoul Azarfarin MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,
IR. Iran. E-mail: [email protected] Tel: 09122018939
Received: June 2, 2016 Accepted: October 16, 2016
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Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
37
ospitalization is an experience full of
stress and anxiety for many patients and
their families. 1 Admission to the
intensive care unit (ICU) after heart surgery is
an important event for the patients and their
families and creates physical and
psychological problems not only for the
patients but also for their families. The
emotional status of the family members can
have positive or negative impacts on the
patients’ response and recovery. 2
Some factors can suddenly affect the health of
the family and change its structure. In fact,
family members are the representative of their
patients hospitalized in the ICU.
Hospitalization of patients in the ICU causes
problems for their family members; problems
that come into conflict with their supportive
role. These problems usually appear in the
form of shock, anxiety, anger,
disappointment, feeling guilty, and fear.
Stress and anxiety are the most common
issues of those families. 3
Studies have shown that the most important
reason for anxiety and stress in a patient’s
family is lack of sufficient information about
the prognosis and treatment of the disease and
unfamiliarity with the ICU environment and
its sophisticated equipment. Family members
want to be informed of changes in the clinical
conditions of their patients as soon as
possible. 4 Various studies have been
conducted to determine the needs of the
families whose patients are hospitalized in the
ICU. Bailey et al 6 classified some of these
needs in 5 groups: 1) need for information, 2)
need for confidence, 3) need for empathy and
sympathy, 4) need for comfort, and 5) need
for psychological support. 5
Nurses can support these families through
establishing effective communication with
them, listening to their worries and feelings,
paying attention to their questions and
answering them, or helping them to find the
answers. 6 They can also respect these
families, support their adaptive mechanisms,
identify the unique needs of each family,
provide them with suitable information to
facilitate coming to decisions about their
patients, and provide the possibility of visiting
and talking to other families in order to
express and share their feelings. Indeed,
nurses can expand the nurse/family
relationship in all the stages of care. 7-10
Accordingly, we sought to investigate the
effects of a nursing supportive program on the
levels of stress and anxiety in the families of
post-cardiac surgery patients admitted to the
ICU.
METHODS
The present study was a quasi-experimental
research to investigate the effects of the
implementation of a nursing supportive
program on the levels of stress and anxiety in
the families of the patients hospitalized in the
ICU after heart surgery in Rajaie
Cardiovascular, Medical, and Research
Center, Tehran, Iran, in 2015. The sample size
required was calculated to be 35 participants
in each group of control and intervention.
After obtaining written informed consent
from all the patients’ families, the researcher
used the convenience sampling method and
selected the samples and classified them in
either the control group or the intervention
group.
On the surgery day, the researcher was
present in the reception part of the surgery
room. The researcher met the patients’
families and selected the family members
who were emotionally closer to the patients.
The inclusion criteria were comprised of
having the main role in supporting the patient,
age > 18 years, not having education in
medical science fields, having enough ability
to understand the subjects in Farsi, and having
no history of known mental illnesses. The
samples of the control and test groups were
similar in relation to variables such as familial
relationship with the patient, age, sex, and
education level.
The control group received the usual
proceedings such as informing the patients’
families in special circumstances. The
H
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Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
38
intervention group received both the usual
proceedings and the supportive program. The
intervention in the present study, including
the nursing supportive program for the
patients’ families, was performed by the
researcher nurse while the patients were
hospitalized in the ICU following cardiac
surgery.
The nursing supportive program lasted for
only 30 minutes and incorporated the
provision of primary facilities such as seats in
a private place to sit and partake of
refreshments, as well as the opportunity for
communication and conveyance of
information not only about the patient’s
clinical status and recovery process according
to the treating physician’s or nurse’s account
but also about the care for patients with
cardiovascular disease (through pamphlets).
Great emphasis was placed upon listening
attentively to the family’s fears and worries,
ensuring them that sufficient care was
provided in the ICU, and helping them not to
lose hope.
We used the Depression Anxiety Stress
Scales (DASS-21), which contains the criteria
for anxiety and stress. The reliability and
validity of the criteria of this questionnaire in
the general population have been previously
investigated and confirmed through a study
by Sahebi et al. 10
Both groups completed the
DASS-21 questionnaire after their patients
had been admitted to the ICU post cardiac
surgery. The intervention program was
commenced 2 hours afterward and
subsequently on the 2nd and 3rd days of the
patients’ ICU stay. The control group
completed the questionnaire on the 1st, 2nd,
and 3rd days of their patients’ ICU stay. Both
groups were compared using SPSS, and the
data were statistically analyzed.
RESULTS
The average age of the participants was 44 ±
2 years. Most of the participants were men:
51.4% of the subjects in the control group and
60% of those in the intervention group were
men. The education level in the majority of
the participants in both groups was high
school diploma: 54.3% of the control group
and 45.7% of the intervention group. In
addition, 88.6% of the participants in both
control and intervention groups were married.
Totally, 54.3% of the participants in the
control group were the children of the
patients. In the intervention group, 60% of the
participants were the wives or the husbands of
the patients. Most of the subjects under study
were housewives: 42.9% in the control group
and 37.1% in the intervention group. Apropos
the place of residence, 82.9% of the
participants in the control group and 94.3% of
those in the intervention group were city
residents. Both groups were homogeneous
vis-à-vis the variables of age, sex, education
level, marital status, familial relationship with
the patient, occupation, and place or
residence; there were no statistically
significant differences between the 2 groups.
As is shown in Table 2, at the beginning of
the study, 28.6% of the participants in the
control group and 37.1% in the intervention
group exhibited normal levels of stress. Most
of the participants experienced moderate and
severe stress. According to the obtained
results, the stress level of the intervention
group decreased during the intervention (ie, 2
hours after the ICU admission of their
patients) and thereafter on the 2nd and 3rd
days of the study. A significant percentage of
the participants reached a normal level of
stress.
In the control group, 77.1% of the participants
experienced extreme anxiety and 20% had
severe anxiety. In the intervention group,
51.4% of the participants experienced extreme
anxiety and 22.9% suffered from severe
anxiety. After the intervention, the level of
anxiety in both groups decreased. However,
because there was a significant difference
between the 2 groups at the beginning, a
regression model was used. Using the
regression model and omitting the
confounding factor (anxiety in both groups at
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Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
39
the beginning was considered the
confounding factor) demonstrated that the
anxiety levels after the 1st intervention (2
hours after ICU admission) and the anxiety
levels on the 2nd ICU day were significantly
different between the control and intervention
groups (P = 0.0001), but there was no
significant difference between the 2 groups on
the 3rd day (P = 0.993).
Table 1. Demographic characteristics of the family members of the patients hospitalized in the intensive care unit
Variables Intervention Group (%)
Control Group (%)
P
Age (y) 40±2 48±1 0.296
Sex Men 51.4 60
Women 48.6 40 0.470
Marital status Married 88.6 88.6
Single 11.4 11.4 1.000
Wife or husband 42.9 60 0.252 Familial
relationship Child 54.3 40
other 2.9 0
Education level lower than high school diploma 34.3 25.7 0.133
high school diploma 54.3 45.7
university 11.4 28.6
Place of residence urban 82.9 94.3 0.203
rural 17.1 5.7
Occupation office worker 2.9 11.4 0.263
worker 5.7 8.6
retired 14.3 20
housewife 42.9 37.1
self-employed 34.3 22.8
Table 2. Comparison of stress levels between the control and intervention groups
Time Baseline
2 Hours After ICU Admission
2nd ICU Day 3rd ICU Day
Group Control Test Control Test Control Test Control Test
Normal stress level 28.6 37.1 57.1 94.3 88.6 97.1 94.3 100
Mild 25.7 28.6 31.4 5.7 8.6 2.9 5.7 0
Moderate 22.9 17.1 11.4 0 2.9 0 0 0
Severe 14.3 22.9 0 0 0 0 0 0
Extreme 8.6 8.6 0 0 0 0 0 0
P 0.359 0.0001 0.044 0.014
Table 3. Comparison of anxiety levels between the control and intervention groups
Time Baseline 2 Hours After ICU
Admission 2nd ICU Day 3rd ICU Day
Group Control Test Control Test Control Test Control Test
Normal stress level 0 0 0 25.7 11.4 88.6 60 95
Mild 2.9 5.4 5.2 42.9 28.6 11.4 40 5
Moderate 0 10.3 25.7 25.7 17.1 0 0 0
Severe 20 22.9 37.1 5.7 31.4 0 0 0
Extreme 77.1 61.4 31.4 0 11.4 0 0 0
P 0.012 0.0001 0.0001 0.0001
DISCUSSION
The findings of the present study showed that
the level of stress in the family members of
the post-cardiac surgery patients hospitalized
in the ICU in the intervention group decreased
significantly after the supportive program,
which was commenced 2 hours after ICU
admission and thereafter on the 2nd and 3rd
ICU days. Additionally, the level of anxiety
dropped after the implementation of the
supportive program and subsequently on the
2nd day of the study. Nonetheless, the
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Nursing Supportive Program and Anxiety and Stress Levels Rezaei T, et al.
40
supportive program did not have a significant
effect on the level of anxiety in the family
members on the 3rd ICU day.
The findings obtained from the present study
correspond to those reported by Muldoon et
al, 11
who designed an interventional study
and investigated the effects of informational
cards on decreasing the stress level in the
families whose patients were in the surgery
room. The authors reported that 55.4% of the
volunteers stated that the information on those
cards was effective in reducing stress. (The
participants’ opinions were recorded as
“agree” and “completely agree”.) In our
study, relevant information was provided
more comprehensively and more extensively
than in the above-mentioned study. The
information provided in the current study (see
METHODS) helped the families cope with
stress and anxiety more effectively. Different
studies have shown that an account of the
patients’ status in the ICU provided by the
nurse helps their families to feel more
hopeful, to be more satisfied with the
personnel, to have more control over the
circumstances, and to experience less stress
and anxiety. Furnishing families with
information about the status of their patients
and expected results, investigating their
feelings such as anger and guilt, informing
them of what has been done and its reason,
and suggesting some care methods which they
can draw upon for their patients can lessen
stress in those families. 10
A study by Imanipour et al, 1 conducted
among the families of cardiac surgery
patients, showed that informational support,
familiarization tours, and educational
pamphlets were not always able to decrease
the families’ anxiety on the discharge day
from the ICU. A study by Bailey et al 6
showed no significant relationship between
informational support and anxiety in the
families of the patients hospitalized in the
ICU. The authors performed a descriptive
cross-sectional study on 29 family members
whose patients were hospitalized in the ICU
and found that those participants who had
received more informational support based on
the CCFNI (Critical Care Family Needs
Inventory) did not necessarily feel less
anxiety, which chimes in with the results of
our study. In other words, the reason why the
intervention did not affect anxiety can be the
factors which cause the anxiety;
consequently, it is necessary to consider all
the causes and prevent them when seeking to
control anxiety, especially when dealing with
patients undergoing major operations such as
coronary artery bypass graft sugary. 12-16
It should be noted that the duration of our
study was limited to the time period during
which the patients were hospitalized in the
ICU because of our limited financial and
human resources. Investigating stress and
anxiety when patients are discharged from the
hospital requires monitoring patients and their
families and continuing the informational
support. These cases are outside the scope of
the duties of the nurses working in the ICU.
CONCLUSIONS
ICU admission can by synonymous with
mental confusion, fear, and anxiety for
patients and their families. Given the
significance of the role of families in the care
of cardiac surgery patients, it is clinically
valuable to decrease—even minimally—their
anxiety levels. The results of our study
demonstrated that the family members of the
post-cardiac surgery patients hospitalized in
the ICU experienced a great degree of stress
and anxiety and interventions such as our
nursing supportive program, giving
informational and emotional support, were
effective in decreasing their levels of stress
and anxiety.
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6. Bailey JJ, Sabbagh M, Loiselle CG, Boileau J,
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satisfaction with care. Intensive and Critical
Care Nursing. 2010;26(2):114-22.
7. Rabie SS, Avazeh A, Eskandari F,
KHALEGH DMT, Mazloom S, Paryad E. A
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patients in intensive care units. IJCCN.
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8. Kaakinen JR, Gedaly-Duff V, Coehlo DP.
Family health care nursing: Theory, practice
and research: FA Davis; 2011.
9. Salahshoor p. The effect of supportive nursing
program on depression, anxiety and stress of
family members of patients during coronary
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Cardiovascular Nursing Journal, 2014;1:3-6.
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Adams J. Implementation of an informational
card to reduce family members' anxiety.
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12. McAdam JL, Fontaine DK, White DB,
Dracup KA, Puntillo KA. Psychological
symptoms of family members of high-risk
Intensive care unit Patients. American Journal
of Critical Care. 2012;21(6):386-94.
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Azarfarin R. Role of platelet parameters and
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Assoc. 2013 Sep;63(9):1133-7.
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Bilehjani E, Ghabili K, Alizadehasl A. Do
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RV Function After PVR in Patients With TOF Moradian M, et al.
42
Original Article RV Function After PVR in Patients With TOF Moradian M, et al.
Echocardiographic Evaluation of Right Ventricular Function After
Pulmonary Valve Replacement in Patients With Tetralogy of Fallot
Maryam Moradian1, MD; Nooraldin Momeni
2*, MD; Behshid Ghadrdoost
1, MS;
Hojat Mortezaeian3, MD; Mohamad Rafi Khorgami
1, MD
ABSTRACT
Background: Pulmonary regurgitation is a common complication after tetralogy of Fallot total
correction (TFTC). Some of these patients may be candidated for pulmonary valve
replacement (PVR) because right ventricular (RV) dysfunction will occur ultimately when a
transannular patch has been used.
The aims of this study were to evaluate echocardiographic parameters in patients who
underwent PVR after TFTC and to determine their outcomes in reference to their
preoperative status.
Methods: Twenty-six patients with severe pulmonary regurgitation, who underwent PVR after
TFTC with the transannular patch in Rajaie Cardiovascular, Medical, and Research Center,
were enrolled. Some echocardiographic parameters were assessed before PVR and
subsequently 1 and 3 months afterward.
Results: Of the echocardiographic parameters, the RV ejection fraction was significantly improved
1 month after PVR (P <0.001), while tricuspid annular plane systolic excursion (TAPSE)
was not changed significantly at 1 month postoperatively (P = 0.27). TAPSE and the RV
ejection fraction were increased significantly at 3 months postoperatively (P < 0.005). The
myocardial performance index (MPI) in both left and right ventricles showed a statistically
significant reduction 3 months after PVR (P < 0.001).
Conclusions: Our data showed that the RV ejection fraction changed early post PVR, while the
changes in the MPI and TAPSE for both ventricles occurred later. Accordingly, these
echocardiographic parameters should be evaluated and recorded serially in patients with
TFTC. Additionally, these quantitative parameters should be assessed in the follow-up of
patients after PVR. (Iranian Heart Journal 2017; 17(4): 42-48)
Keywords: Pulmonary valve replacement● Pulmonary regurgitation● Tetralogy of Fallot●
Tricuspid annular plane systolic excursion
1 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Department of Pediatric Cardiology, Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Tehran, I.R. Iran 3 Cardiovascular Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,
I.R. Iran.
*Corresponding Author: Nooraldin Momeni, MD; Department of Cardiology, Baqiyatallah University of Medical Sciences, Mollasadra Avenue, Tehran, I.R. Iran.
E-mail: [email protected] Tel: 09123147174
Received: June 15, 2016 Accepted: September 21, 2016
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RV Function After PVR in Patients With TOF Moradian M, et al.
43
he surgical repair of tetralogy of Fallot
has been performed for several years,
with desirable early and long-term
outcomes. Despite improvement in the
operative techniques and early management in
tetralogy of Fallot total correction (TFTC),
the majority of the patients are exposed to
chronic pulmonary regurgitation as a result of
reconstructive surgery to relieve the
obstruction in the right ventricular (RV)
outflow tract. 1, 2
Although it has been shown that the left
ventricular (LV) function is usually well
preserved after early TFTC, the RV volumes
may increase and the ejection fraction (EF)
may decrease. 3
The severity of pulmonary regurgitation and
the RV volume overload, as important
postoperative adverse outcomes, is directly
related to RV dilation and its role is known as
a cause of arrhythmia and sudden cardiac
death. 4
A growing body of evidence demonstrates the
clinical importance of the timely
identification of deteriorating ventricular size
and function after TFTC. Be that as it may,
deciding when to perform pulmonary valve
replacement (PVR) is a challenging issue for
all congenital heart disease clinicians. 5
Timely PVR can reduce RV volume overload
and improve functional class and exercise
capacity. PVR, therefore, has potentially
favorable outcomes despite the high risks
associated with it. 6
Although cardiovascular magnetic resonance
imaging (CMR) is considered the best and
most accurate method for evaluating the RV
size and function and quantification of PVR,
it is expensive and not always available. On
the other hand, echocardiography is more
available and its cost makes it the 1st method
of choice for this purpose, notwithstanding its
poor performance in viewing the RV free wall
and fractional area in comparison with
CMR.7, 8
Echocardiographic assessment of the RV
systolic function is, nevertheless, limited by
the complex RV geometric shape. Other
techniques such as M-mode-derived tricuspid
annular plane systolic excursion (TAPSE) and
the RV myocardial performance index (MPI)
seem to be able to overcome these
limitations.9
The aims of the present study were to
evaluate some echocardiographic parameters
of patients undergoing PVR after TFTC and
to determine their outcome in reference to
their preoperative status.
METHODS
Thirty-six patients with severe pulmonary
regurgitation, candidated for PVR after TFTC
with the transannular patch in Rajaie
Cardiovascular, Medical, and Research
Center, between 2014 and 2015, were
enrolled. Based on the CMR data, the study
population had an r > 165 mL/m2 and an
RVEF < 45%.
The exclusion criteria were death, embedded
RV conduit to the pulmonary artery for
TFTC, considerable residual defects
(including ventricular septal defects, severe
pulmonary stenosis, more-than-mild tricuspid
regurgitation, and paravalvular leakage
following PVR), and major arrhythmias.
Seven patients were excluded with respect to
these exclusion criteria. Transthoracic
echocardiography was performed by an
experienced cardiologist using a Vivid 3 (GE
Vingmed Ultrasound AS, Horten, Norway
equipped with a 3-MHz transducer). All the
measurements were made in 3 cardiac cycles,
and the averages were used for the statistical
analyses.
For each patient, echocardiography was
performed immediately prior to PVR and then
1 and 3 months afterward. Echocardiographic
indices, namely TAPSE, RVEF (the Simpson
1-plane method), and the MPI (MPI for both
ventricles), were assessed. In the apical 4-
chamber view, the RV end-diastolic and end-
systolic diameters were traced and the RVEF
was calculated via the Simpson method.
TAPSE was assessed via the M-mode (Fig.
1). The MPI was evaluated by using Doppler
T
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modality in the apical 5-chamber view for the
LV and in both 4-chamber view and
parasternal short-axis view for the RV. The
average of the 3 measurements was recorded
for each echocardiographic parameter (Fig.
2). The QRS duration in the ECG trace was
also evaluated in all the patients before PVR
and subsequently 1 and 3 months afterward.
Other demographic characteristics of the
patients as well as clinical signs and
intraoperative data such as operation duration
and the type of the valve (mechanical or
bioprosthetic) used in PVR were recorded and
analyzed. All the surgical operations were
performed by 3 experienced pediatric cardiac
surgeons and in an almost similar anesthetic
situation. The local research ethics
committees approved the study, and all the
subjects (and/or a parent/guardian) gave
written informed consent.
Figure 1. Tricuspid annular plane systolic excursion
(TAPSE) in the lateral apical 4-chamber view by M-mode.
Figure 2. Myocardial performance index (isovolumic
contraction time + isovolumic relaxation time /ejection time).
RESULTS
Twenty-nine patients at a mean age of 11.8
years (range = 6.4–18.9 y), comprised of 14
male and 15 female individuals, were
prospectively studied before PVR and
subsequently 1 and 3 months afterward. The
baseline and surgery-related characteristics of
all the patients are depicted in Table 1. As is
shown in Table 2, among the
echocardiographic parameters, the RVEF was
significantly improved 1 month after PVR (P
< 0.001), whereas TAPSE was not changed
significantly at 1 month postoperatively (P =
0.27). The QRS duration exhibited no
statistically significant change within a month
after surgery (P = 0.08).
The changes in the echocardiographic
parameters were significant in the 3rd
postoperative month (Table 3). The RVEF
and TAPSE were increased significantly at 3
months postoperatively (P <0.005). The MPI
in both ventricles showed a statistically
significant reduction 3 months after PVR (P <
0.001).
In ECG, the QRS duration was reduced
significantly at 3 months postoperatively.
The correlation between the echocardio-
graphic parameters and age and time interval
between TFTC and PVR are depicted in Table
4. Age correlated significantly with TAPSE 1
month after PVR (r = 0.563; P = 0.001) and
with TAPSE 3 months after PVR (r = 0.589;
P = 0.005). The time interval between TFTC
and PVR had a significant correlation with
TAPSE 1 month after PVR (r = 0.511; P =
0.005) and with TAPSE 3 months after PVR
(r = 0.515; P = 0.004). The other
echocardiographic variables had no
significant correlations with age and the time
interval between TFTC and PVR.
Table 5 shows the correlation between the
RVEF and the QRS duration. There was an
inversely significant correlation between the
RVEF 1 month after PVR and the QRS
duration (P < 0.05), while there was no
significant correlation between the RVEF and
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the QRS duration 3 months after PVR
(P>0.05). The correlation between the RVEF
and TAPSE can also be seen in Table 5.
There was no significant correlation between
the RVEF and TAPSE (P > 0.05).
Table 1. Baseline and surgery-related characteristics of all the patients
Variables M±SD / N (%)
Age (y) 11.8±2.6
Sex (female/male) 15/14
Time interval between TFTC and PVR (y) 8.02±2.49
Clinical signs
Resting dyspnea and fatigue 10 (34.5%)
Exertional dyspnea and fatigue 19 (65.5%)
Type of valve used in PVR
biological 11 (37.9%)
mechanical 18 (62.1%)
Cardiothoracic ratio on CXR
normal 0 (0%)
top normal 1 (3.4%)
increased 28 (96.6%)
PVR, Pulmonary valve replacement; TFTC, Tetralogy of Fallot total correction; CXR, Chest X-ray
Table 2. Echocardiographic parameters before and 1 month after PVR
Before PVR 1 Month After PVR P
QRS duration (msec) 160.86±17.27 159±16 0.08
TAPSE (cm) 1.51±0.16 1.48±0.15 0.27
RVEF (%) 41.37±4.12 45.06±16 <0.001
PVR, Pulmonary valve replacement; RVEF, Right ventricular ejection fraction; TAPSE, Tricuspid annular plane systolic excursion
Table 3. MPI and echocardiographic parameters before and 3 months after PVR
Before PVR 3 Months After PVR P
QRS duration (msec) 160.86±17.27 158±16 <0.001
TAPSE (cm) 1.51±0.16 1.58±0.12 0.005
RVEF (%) 41.37±4.12 48.3±2.9 <0.001
RV MPI 0.36±0.009 0.34±0.09 <0.001
LV MPI 41.37±0.01 0.39±0.01 <0.001
MPI, Myocardial performance index; PVR, Pulmonary valve replacement; RVEF, Right ventricular ejection fraction; TAPSE, Tricuspid annular plane systolic excursion
Table 4. Correlation between the echocardiographic parameters and age and time
interval between TFTC and PVR
Age Time Interval Between TFTC and PVR
Pearson Correlation
P Pearson Correlation
P
TAPSE 1*
0.563 0.001 0.511 0.005
RVEF 1* 0.051 0.79 0.141 0.46
RV MPI 2**
0.285 0.13 0.179 0.35
LV MPI 2** 0.257 0.17 0.333 0.07
TAPSE 2** 0.589 0.001 0.515 0.004
RVEF 2** 0.006 0.97 0.170 0.37
TFTC, Tetralogy of Fallot total correction; RVEF, Right ventricular ejection fraction; LV, Left ventricle; MPI, Myocardial performance index; TAPSE, Tricuspid annular plane systolic excursion *: 1 month after PVR **: 3 months after PVR
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Table 5. Correlation between the RVEF and TAPSE and the QRS duration
RVEF 1 RVEF 2
Pearson Correlation
P Pearson Correlation
P
TAPSE 1* 0.255 0.18 0.142 0.46
TAPSE 2**
0.202 0.29 0.111 0.56
QRS duration 1* -0.390 0.036 -0.311 0.10
QRS duration 2** -0.447 0.015 -0.348 0.06
RVEF, Right ventricular ejection fraction; TAPSE, Tricuspid annular plane systolic excursion *: 1 month after PVR
**: 3 months after PVR
DISCUSSION
One of the most frequently performed
pediatric cardiac surgeries in our country is
TFTC. This surgical modality can be
accompanied by pulmonary insufficiency and
progressive RV dilatation and dysfunction if
it requires a transannular incision to relieve
RV outflow obstruction. In the follow-up of
these patients, the pediatric cardiologist
should decide when to perform PVR, which is
a seriously challenging decision. Recently in
our country, an increasing number of pediatric
patients with TFTC have undergone PVR.
Given the significance of their medical
follow-up, it is advisable that the simplest
echocardiographic methods be employed
because some echocardiography machines,
especially those in remote areas, are not
equipped with tissue Doppler and strain and
strain rate software (latest techniques to
evaluate the RV function).
Surgical PVR normalizes the RV dimensions,
improves RV and LV contractility, and
reverses the clinical symptoms. 10
A proper
assessment of the severity of pulmonary
regurgitation and the RV function is of great
value in the follow-up of patients post PVR.
Echocardiography plays an essential role in
the longitudinal follow-up in these patients. 11
After PVR surgery, most patients feel better
because of improvement in their New York
Heart Association’s functional class. In most
of the patients with an effective relief of
pulmonary regurgitation, the RV volumes
become normal and the RV performance (EF)
improves significantly. 5 During our study
period, the RVEF showed a considerable
improvement among our patients, with the
improvement manifesting itself even in the
1st postoperative month.
Currently, the evaluation of the RV shape is
carried out using TAPSE. TAPSE has a
significant correlation with the RVEF. 8 In
our study, although TAPSE was changed
significantly over time after PVR, we did not
find any correlation between TAPSE and the
RVEF. It could have been due to the low
number of patients in our study. We also
found a significant correlation between
TAPSE and the time interval between TFTC
and PVR. It seems logical that if PVR is
performed before severe RV dysfunction
develops, improvement in the RV function
will be more possible.
The MPI, as a relatively newer Doppler
technique, is a reliable method for the
evaluation of the systolic and diastolic
performances of both ventricles, particularly
in congenital heart disease. In the current
study, the MPI of both ventricles was reduced
significantly 3 months after TFTC. Abdel
Rahman et al 12
studied 50 patients who had
TFTC and observed that those with severe
pulmonary valve regurgitation who had a
reduced RVEF showed a significant increase
in the RV MPI.
QRS prolongation is a known marker of RV
dilation, and a reduction in the QRS duration
shows excellent freedom from arrhythmias
after PVR. 6 In the current study, we
demonstrated that the QRS duration was
mainly allied to the RVEF and that the QRS
duration decreased within 3 months after
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surgery. A study by van Huysduynen et al 13
reported a reduction in the QRS duration 14
months after PVR, regarding improvement in
the LV end-diastolic volume.
In summary, our data suggest that the MPI
and TAPSE are reliable parameters for the
evaluation of the LV systolic function. Thus,
they may provide a quantitative tool to assess
pulmonary regurgitation by echocardio-
graphy, although further validation is required
to confirm the utility. Moreover, timely PVR,
which prevents RV dilation, has a beneficial
effect on the QRS duration
CONCLUSIONS
Echocardiography has a limited ability to
quantify the RV function due to its complex
geometry. Some patients after TFTC will
need PVR; this is a scenario that is on the rise
in pediatric patients. CMR is the gold
standard for the evaluation of the RVEF and
the RV end-systolic and diastolic volumes
with a view to selecting patients for PVR after
TFTC. In pediatric patients who have
undergone PVR, echocardiographic
evaluation of the RV function using TAPSE,
RVEF by the Simpson method, and the MPI
is valuable and simply accessible. We would,
therefore, recommend that these simple and
cost-effective modalities be utilized in the
follow-up of these patients, especially when
echocardiographic machines are not equipped
with tissue Doppler and strain and strain rate
modalities.
Financial Disclosure: This research received
no specific grant from any funding agency,
commercial or not-for-profit sectors.
Conflict of Interest: None.
Ethical Standards: This study was approved
by our local ethics committee in accordance
with the Helsinki Declaration of the World
Medical Association (2000). All the patients
provided written informed consent prior to the
commencement of the study.
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1. Cheul Lee. Surgical Management of Chronic
Pulmonary Regurgitation After Relief of
Right Ventricular Outflow Tract Obstruction.
Korean Circ J. 2012 Jan; 42(1): 1–7.
2. Gatzoulis MA, Balaji S, Webber SA, Siu SC,
Hokanson JS, Poile C, Rosenthal M,
Nakazawa M, Moller JH, Gillette PC, Webb
GD, Redington AN. Risk factors for
arrhythmia and sudden cardiac death late after
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study. Lancet. 2000 Sep 16;356(9234):975-81.
3. Gatzoulis MA, Clark AL, Cullen S, et all.
Right ventricular diastolic function 15 to 35
years after repair of tetrallogy of fallot.
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4. Fogel MA, Pawlowski T, Keller MS, Cohen
MS, Goldmuntz E, Diaz L, Li C, Whitehead
KK, Harris MA. The Cardiovascular Effects
of Obesity on Ventricular Function and Mass
in Patients after Tetralogy of Fallot Repair. J
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5. Frigiola A, Tsang V, Bull C, Coats L,
Khambadkone S, Derrick G, Mist B, Walker
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Biventricular response after pulmonary valve
replacement for right ventricular outflow tract
dysfunction: is age a predictor of outcome?
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6. Lee C, Kim YM, Lee CH, Kwak JG, Park CS,
Song JY, Shim WS, Choi EY, Lee SY, Baek
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11;60(11):1005-14.
7. Wald RM1, Valente AM2, Gauvreau K2,
Babu-Narayan SV3, Assenza GE2, Schreier
J2, Gatzoulis MA3, Kilner PJ3, Koyak Z4,
Mulder B4, Powell AJ2, Geva T2. Cardiac
magnetic resonance markers of progressive
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Imaging. 2009 Mar;25(3):271-5.
9. Mercer-Rosa L, Yang W, Kutty S, Rychik J,
Fogel M, Goldmuntz E. Quantifying
pulmonary regurgitation and right ventricular
function in surgically repaired tetralogy of
Fallot: a comparative analysis of
echocardiography and magnetic resonance
imaging. Circ Cardiovasc Imaging. 2012 Sep
1;5(5):637-43. Epub 2012 Aug 6.
10. Lindsey CW, Parks WJ, Kogon BE, Sallee D
3rd, Mahle WT. Pulmonary valve replacement
after tetralogy of Fallot repair in preadolescent
patients. Ann Thorac Surg. 2010
Jan;89(1):147-51.
11. Erdem S1, Ozbarlas N, Küçükosmanoğlu O,
Poyrazoğlu H, Salih OK. Mid-term results of
patients following total surgical correction of
tetralogy of Fallot. Turk J Pediatr. 2012 Jul-
Aug;54(4):393-402.
12. Abd El Rahman MY, Abdul-Khaliq H, Vogel
M, Alexi-Meskishvili V, Gutberlet M, Lange
PE. Relation between right ventricular
enlargement, QRS duration, and right
ventricular function in patients with tetralogy
of Fallot and pulmonary regurgitation after
surgical repair. Heart 2000; 84: 416-20.
13. van Huysduynen BH, van Straten A, Swenne
CA, et al. Reduction of QRS duration after
pulmonary valve replacement in adult Fallot
patients is related to reduction of right
ventricular volume. Eur Heart J 2005;26:928–
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Development of Heart Failure Following Pace Maker Implantation in a Patient With Congenital Heart Block Doostali K, et al.
49
Case Report Development of Heart Failure Following Pace Maker Implantation in a Patient With Congenital Heart Block Doostali K, et al.
Development of Heart Failure Following Pace Maker
Implantation in a Patient With Congenital Heart Block
Kobra Doostali1, MD; Sedigheh Saedi
2, MD; Tahereh Saedi
2*, MD
ABSTRACT
Congenital complete heart block (CCHB) is a rare anomaly and is a potential indication for
pacemaker implantation. However, pacemakers might lead to cardiomyopathy. Here we describe a
young woman with CCHB presenting with heart failure early postpartum and pacemaker
implantation.
Keywords: Complete heart block● Pacemaker-induced cardiomyopathy● Peripartum cardiomyopathy
1 Department of Cardiology, Shahid Beheshti, Qom University of Medical Sciences, Qom, I.R. Iran. 2 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.
*Corresponding Author: Tahereh Saedi, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.
E-mail: [email protected] Tel: 02123922003
Received: April 6, 2016 Accepted: October 10, 2016
ongenital complete heart block (CCHB)
can be isolated or occur in the setting of
systemic autoimmune disorders or
structural heart disease. 1 The patients could
be asymptomatic or have minimal symptoms,
so the diagnosis may be delayed and
symptoms interpreted for other causes. 1 Once
CCHB is diagnosed, pacemaker implantation
is indicated for patients with symptomatic and
significant bradycardia. 1 On the other hand,
one potential complication of pacemakers in
this group is reported to be the development
of cardiomyopathy. 2
We herein describe a patient with CCHB,
who received a permanent pacemaker (PPM)
in her postpartum period and presented with
early-onset congestive heart failure.
CASE REPORT
A 27-year-old 1st gravid woman, in her 38
weeks of gestation, who was admitted to our
hospital for termination of pregnancy, was
found to have significant bradycardia during
routine cardiac monitoring. ECG showed a
heart rate of about 40 bpm with recorded
narrow QRS complexes having no relation to
atrial contraction (A-V dissociation) (Fig. 1).
She had no history of syncope but mentioned
episodes of exertional dizziness and easy
fatigability. She had no past medical history
of significant systemic illnesses or drug use.
Cardiology consult was performed and
because the patient was currently
asymptomatic and had a narrow QRS
response, she was scheduled to have natural
vaginal delivery under cardiac monitoring
with percutaneous temporary pacemakers
being kept at hand in case she became more
bradycardic or developed asystole. The
delivery course was uneventful, and cardiac
monitoring was continued in the postpartum
phase for 5 days, during which she remained
in complete heart block. Transthoracic
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echocardiography was done; it showed
normal left ventricular (LV) size and systolic
function (left ventricular ejection fraction
[LVEF] = 55%) as well as normal right
ventricular (RV) size and function with no
significant valvular heart disease. A PPM was
implanted for the patient, and she was
discharged home in a good condition (Fig. 2).
Figure 1. Twelve-lead ECG depicts 2:1 atrioventricular (AV) block with intermittent complete
AV block and junctional escape rhythm of about 40–45 beats per minute.
Figure 2. Twelve lead ECG shows a right ventricular-paced rhythm after atrial sensing.
After 45 days, the patient referred to the
emergency department complaining of
dyspnea on exertion (New York Heart
Association’s functional class 3), fatigue,
palpitation, and chest pain. She was admitted
for further evaluation. ECG showed normal
function of the pacemaker, but transthoracic
echocardiography revealed a normal LV size
with severe LV systolic dysfunction (LVEF =
10%–15%). On chest X-ray, the pacemaker
leads were seen in proper position in the RV
apex and the right atrial appendage. Analysis
of the PPM showed a normal pacemaker
function. Laboratory tests, including troponin
I and renal and liver function tests, as well as
rheumatologic evaluations revealed no
abnormality. Due to persistent chest pain,
coronary angiography was performed to
evaluate for an abnormal course, coronary
slow flow, or other abnormalities.
Nonetheless, all the coronary arteries were
patent and had normal courses. 3
Medical therapy for heart failure was started
with lisinopril, spironolactone, and carvedilol.
The patient’s symptoms were relieved a few
days after the beginning of the therapy, and
she was discharged after a week.
Serial follow-up transthoracic echocardio-
graphic examinations showed gradual
improvement in LV contractility and there
was a reported LVEF of 35% twelve months
after the medical therapy for heart failure.
DISCUSSION
Our patient was a case of asymptomatic and
most probably CCHB. She developed rapid-
onset congestive heart failure within 45 days
after delivery and receiving a PPM.
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The underlying cause of this event remains
ambiguous. Indeed, did the patient suffer
from coincidental peripartum cardiomyopathy
(PPCM) or did she actually develop
pacemaker-induced cardiomyopathy?
PPCM is an uncommon cardiomyopathy that
results in myocardial damage in the late
phases of pregnancy and the early postpartum
period, causing maternal morbidity and
mortality. 4 The reported incidence is variable
in different communities and ethnicities, and
diverse risk factors have been implicated. 4
PPCM is clinically similar to dilated
cardiomyopathy, but the course and prognosis
are unpredictable. 4 The diagnosis is made
based on the occurrence of de novo heart
failure during the terminal months of
pregnancy or the initial 5 months after the
delivery in the absence of cardiac anomalies
before pregnancy. It is usually reached by the
exclusion of other possible causes. The
transthoracic echocardiography criteria 4
include LVEF < 45%, fractional shortening <
30%, and LV end-diastolic dimension > 2.7
cm/m2. Despite the definitions, PPCM could
occur beyond the mentioned time period
either earlier in the pregnancy or later
postpartum. Indeed, about 13% of the cases
are thought to happen outside the defined
timeline, leading to underdiagnosis. 4
The standard therapy for CCHB and
significant bradyarrhythmias is the
implantation of PPMs. The RV lead is often
placed in the apical area. In this situation,
electrical impulse conduction happens
through the myocardial cells and outside the
normal conduction pathway. 5, 6
The
stimulation starts from the RV, which causes
dyssynchronous cardiac stimulation and a
wide QRS complex of left bundle branch
block morphology. 5,7
Pacemaker-induced
heart failure is a known complication of RV
pacing, with a reported incidence of 10% in
patients with CCHB and 9%–10% in the
general population in different studies. 2, 8
The
more the RV is paced (> 40% of cardiac
cycles), the greater the risk of
cardiomyopathy will be. Pacemaker-induced
cardiomyopathy is defined echocardio-
graphically as an LVEF < 45% and a decrease
>5% in the LVEF as compared to the baseline
EF in the 1st year post PPM implantation.
That is the reason why some studies have
suggested that individuals who are completely
pace-dependent receive biventricular
pacemakers regardless of baseline patient
characteristics. 2, 9
The definite diagnosis is challenging in this
case due to the time overlap of the responsible
pathologies. However, the question is whether
there is a greater tendency of the development
of pacemaker-induced cardiomyopathy in the
early postpartum period.
Pregnancy leads to significant hemodynamic
changes, including increases in plasma
volume and heart rate, which could be
damaging in mothers with baseline cardiac
diseases 10
or perhaps render the myocardium
more vulnerable to the pacing effects early
after delivery. Future molecular and genetic
studies might be able to elucidate the exact
pathologic insult at the myocyte level.
CONCLUSIONS
PPCM and pacemaker-induced cardiomyo-
pathy are 2 rather uncommon entities leading
to variably reversible cardiomyopathy. In the
current case, the 2 mentioned pathologies
seemed to coincide with the possibility of
simultaneous or additive harmful effects on
the myocardium.
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it time to avoid the right ventricular free wall?
Eur Heart J. 2009 May;30(9):1033-4. doi:
10.1093/eurheartj/ehp130. Epub 2009 Apr 2.
8. Oliveira Júnior RM, Silva KR, Kawauchi TS,
Alves LB, Crevelari ES, Martinelli Filho M,
Costa R. Functional capacity of patients with
pacemaker due to isolated congenital
atrioventricular block. Arq Bras Cardiol. 2015
Jan;104(1):67-77. doi: 10.5935/abc.20140168.
Epub 2014 Nov 11.
9. Barold SS, Israel CW. The changing
landscape of cardiac pacing.
Herzschrittmacherther Elektrophysiol. 2015
Mar;26(1):32-8. doi: 10.1007/s00399-014-
0346-2
10. Braunwald’s heart disease. Mann, Zips,
Libby, Bonow.10th edition.pages 1755-1767
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Case Report Anomalous Trifurcation of the Left Main Coronary Artery: A Case Report Saed D, et al.
Anomalous Trifurcation of the Left Main Coronary Artery:
A Case Report
Daryoush Saed*1, MD; Peyman Arasteh
2, MD; Mehran Purnazari
3, MD
ABSTRACT
Coronary artery anomalies are rare with an incidence rate < 1%. The presentation varies
considerably. We present the case of an anomalous left atrial branch from the left main coronary
artery without independent clinical manifestations. (Iranian Heart Journal 2017; 17(4): 53-56)
Keywords: Coronary artery anomaly● Coronary angiography● Diagnosis
1 Echocardiography Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences,
Tehran, I.R. Iran. 2 MPH Department, Noncommunicable, Research Center, Fasa University of Medical Sciences, Fasa, I.R. Iran. 3 Tehran University of Medical Sciences, Tehran, I.R. Iran.
*Corresponding Author: Daryoush Saed, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical
Sciences, Tehran, I.R. Iran.
E-mail: [email protected] Tel: 09124224581
Received: March 7, 2016 Accepted: September 14,2016
nomalies originating from the
coronary arteries are extremely rare,
with an incidence ranging from 0.17%
to 1.3% in autopsy and angiographic findings,
respectively. 1, 2
The anomalies can manifest
with a wide range of symptoms, including
arrhythmias, myocardial infarction, and even
in some cases sudden death—especially in the
congenital anomalies associated with
hemodynamic instability. 3, 4
The left main
coronary artery (LMCA) bifurcates into 2
main branches: the left anterior descending
artery (LAD) and the left circumflex artery
(LCx). The left atrial coronary artery branches
form the LCx. 5
We describe a 54-year-old woman, who
presented with an unusual trifurcation of the
LMCA.
CASE REPORT
The case presented herein is a 54-year-old
woman, a known case of hypertension, who
referred with chief complaints of dyspnea and
epigastric pain from 7 days prior to her
admission. The epigastric pain and dyspnea
had an on-and-off pattern, until the day prior
to her admission, on which she had an
exacerbation of symptoms and referred for
treatment.
In her past medical history, the patient
mentioned a history of hypertension, for
which she was on antihypertensive
medication (losartan 25 mg twice a day). She
had a family history of coronary artery
disease in her sister.
The patient on presentation was anorexic and
had dyspnea and dry coughs. On admission,
she had a blood pressure of 165/120 mm Hg
(bilateral), pulse rate of 116 bpm, respiratory
rate of 25 bpm, and temperature of 37°C.
Physical examination revealed an apical
systolic murmur of mitral regurgitation and an
S3 gallop at the apex. Routine lab data
A
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Anomalous Trifurcation of the Left Main Coronary Artery: A Case Report Saed D, et al.
54
revealed normal results, including
hemoglobin and creatinine.
In her hospital workup, the patient underwent
echocardiography, which showed an ejection
fraction of 15%–20%, moderate-to-severe
pulmonary artery hypertension, and severe
mitral regurgitation. Two weeks after her
initial hospitalization, she underwent
transesophageal echocardiography, which
revealed a severely enlarged left ventricle
with global hypokinesia, left ventricular
ejection fraction of 25%, mild functional
mitral valve regurgitation due to annular
dilation, mild tricuspid regurgitation with a
pulmonary arterial pressure of 30–35 mm Hg,
and a normal-sized right ventricle with a
preserved right ventricular function.
The ECG of the patient was in favor of
coronary artery disease (Fig. 1).
Figure 1. Patient’s ECG.
The patient also underwent coronary
angiography through the right femoral
approach, which revealed 2-vessel disease.
She had nonobstructive coronary artery
disease in the LAD, right coronary artery
(RCA), and LCx as well as significant ostial
disease in the diagonal and obtuse marginal
branches. Angiographic evaluation showed an
unusual left atrial branch, originating from the
mid shaft of the LMCA, which traveled
through the left atrium (Supplement 1).
Recommendation:
Medical follow-up for coronary artery disease
and transesophageal echocardiographic
evaluation for mitral regurgitation should be
undertaken.
Afterload reduction with vasodilators and
diuretic therapy for congestive symptoms
were commenced. The patient’s symptoms
significantly improved with medical therapy.
Informed consent was taken before
angiography.
DISCUSSION
The distribution and prevalence of anomalies
related to the coronary arteries differ
worldwide, and they are most commonly
believed to be related to genetic factors.
Categories and Symptoms
The anomalies related to the coronary system
can be divided into 3 different types based on
the anatomy of the coronary arteries: those
with an anomalous origin, those with an
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unusual course, and those with a coronary
artery fistula. 6
In another classification, based on the
pathophysiology of the coronary arteries, the
anomalies are classified into 4 classes. Class I
comprises the anomalies that are associated
with few or no symptoms and are usually
clinically silent. Class II is associated with a
high chance of myocardial ischemia and is
clinically loaded. Class III is associated with
sudden death in young adults and athletes,
and Class IV contains those that are
associated with higher risks for coronary
artery disease. 7
The anomalies of the coronary arteries may
present with different symptoms, ranging
from a set of life-threatening manifestations
such as the symptoms seen in patients with
the anomalous origin of the coronary arteries
from the pulmonary artery, to mild and
sometimes asymptomatic manifestations—as
seen in patients with the anomalous origin of
the RCA or the LMCA from the ascending
aorta. 8, 9
The anomalies of the coronary arteries are
usually associated with other congenital heart
problems such as the Hurler syndrome, the
Friedrich ataxia, tetralogy of Fallot, and other
congenital diseases. 7
Diagnosis
There are different diagnostic modalities for
the detection of the anomalies of the coronary
system. Up to this date, the gold standard for
the diagnosis of these anomalies is still
conventional coronary angiography. 10
Recently, some other diagnostic methods
have been introduced; they include magnetic
resonance angiography, transthoracic
echocardiography, multislice computed
tomography, and electron beam tomography. 7
To the best of our knowledge, only 1 other
case of an anomalous left atrial branch form
the LMCA has been reported. 5
Our patient displayed a new type of anomaly,
which was in the category of anomalies
related to the origin (ectopic coronary origin).
6 Our patient presented with some symptoms
unrelated to this condition.
CONCLUSIONS
Understanding the anomalies related to the
coronary symptoms and their specific clinical
manifestations assists in correct decision-
making for this group of patients. The
anomalous trifurcation of the LMCA is
especially important during ablation in
patients with atrial fibrillation.
REFERENCES
1. Graidis C, Dimitriadis D, Karasavvidis V,
Dimitriadis G, Argyropoulou E, Economou F,
et al. Prevalence and characteristics of
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population undergoing multidetector-row
computed tomography for the evaluation of
coronary artery disease. BMC cardiovascular
disorders. 2015;15(1):112.
2. Yamanaka O, Hobbs RE. Coronary artery
anomalies in 126,595 patients undergoing
coronary arteriography. Catheterization and
cardiovascular diagnosis. 1990;21(1):28-40.
3. Datta J, White CS, Gilkeson RC, Meyer CA,
Kansal S, Jani ML, et al. Anomalous coronary
arteries in adults: depiction at multi-detector
row CT angiography. Radiology.
2005;235(3):812-8.
4. de Jonge GJ, van Ooijen PM, Piers LH,
Dikkers R, Tio RA, Willems TP, et al.
Visualization of anomalous coronary arteries
on dual-source computed tomography.
European radiology. 2008;18(11):2425-32.
5. Gholoobi A. Anomalous Origin of the Left
Atrial Branch from the Left Main Trunk. The
Journal of Tehran University Heart Center.
2015;10(2):113-4.
6. Laspas F, Roussakis A, Mourmouris C,
Kritikos N, Efthimiadou R, Andreou J.
Coronary artery anomalies in adults: imaging
at dual source CT coronary angiography.
Journal of medical imaging and radiation
oncology. 2013;57(2):184-90.
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7. Cademartiri F, Runza G, Luccichenti G, Galia
M, Mollet NR, Alaimo V, et al. Coronary
artery anomalies: incidence, pathophysiology,
clinical relevance and role of diagnostic
imaging. La Radiologia medica.
2006;111(3):376-91.
8. Kim SY, Seo JB, Do K-H, Heo J-N, Lee JS,
Song J-W, et al. Coronary Artery Anomalies:
Classification and ECG-gated Multi–Detector
Row CT Findings with Angiographic
Correlation 1. Radiographics. 2006;26(2):317-
33.
9. Montaudon M, Latrabe V, Iriart X, Caix P,
Laurent F. Congenital coronary arteries
anomalies: review of the literature and
multidetector computed tomography
(MDCT)-appearance. Surgical and Radiologic
Anatomy. 2007;29(5):343-55.
10. Mainwaring RD, Lamberti JJ. Pulmonary
atresia with intact ventricular septum. Surgical
approach based on ventricular size and
coronary anatomy. The Journal of thoracic
and cardiovascular surgery. 1993;106(4):733-
8.
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