issn: 1735-7306 - journal.iha.org.irjournal.iha.org.ir/files/journal/issue_9.pdf · abdi s....

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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

http://www.sid.ir/

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OFFICIAL QUARTERLY PUBLICATION OF THE IRANIAN HEART ASSOCIATION

2

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

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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]

mailto:[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 18, Number 1 (Spring, 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

http://www.sid.ir/

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OFFICIAL QUARTERLY PUBLICATION OF THE IRANIAN HEART ASSOCIATION

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Volume 18, Number 1

Spring, 2017

CONTENTS: Page

ORIGINAL ARTICLES: CLINICAL SCIENCE

Efficacy of the “Head-Up Position” in Returning Cardiopulmonary Bypass Blood to the

Patient and Reducing the Required Blood Transfusion: A Randomized Trial

Rasoul Azarfarin; Majid Dashti; Ziae Totonchi; Mohsen Ziyaeifard; Mohamadjavad

Mehrabanian; Azin Alizadehasl; Farhad Gorjipour

6-15

Results of 3 Years’ Experience in Pulmonary Embolectomy: A Single-Center Experience

Aliasghar Moeinipour; Mohammad Abbasi Teshnizi; Atefeh Ghorbanzadeh;

Mohammad Sobhan Sheikh Andalibi; Mohamadreza Akbari; Hamid Hoseinikhah

16-19

Comparison of Serum Prolactin Levels Between the Acute Phase of Heart Failure and After

Guideline-Directed Medical Therapy

Fatemeh Shiokhi Ahmad Abad; Ahmad Amin; Roya Rezai; Maryam Mofidi Astaneh;

Akram Nakhaie Amrodi; Nasim Naderi; Sepide Taghavi

20-24

Comparison of the Coronary Vessel Diameter During and After Primary Percutaneous

Intervention in Patients with Acute Myocardial Infarction

Farshad Shakerian; Roya Rezai; Fatemeh Shiokhi; Ata Firouzi; Hamidreza Sanati;

Ali Zahedmehr; Reza Kiani; Omid Shafe; Samaneh Ahmadi

25-29

Cardiovascular Magnetic Resonance in Predicting the Reduction in Pulmonary Artery

Pressure in Patients With Mitral Stenosis After Surgical or Interventional Treatment

Hamidreza Sanati; Reza Rezaei Tabrizi; Hamid Reza Pouraliakbar; Ali Zahedmehr;

Ata Firouzi; Farshad Shakerian; Reza Kiani; Nasim Naderi

30-36

Outcome of Carotid Stenting in Patients Undergoing Angioplasty Seifolah Abdi; Faramarz Amiri; Omid Shafe; Reza Ebrahmi Rad; Hamid Fakhreddin;

Alireza Jebeli; Seyed Abdullah Sayadmanesh; Moslem Shadmani; Ebrahim Ghobadi

37-43

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CONTENTS: Page

ORIGINAL ARTICLES: CLINICAL SCIENCE

Effects of Lavender Oil Inhalation on Anxiety and Pain in Patients Undergoing Coronary

Angiography

Mohsen Ziyaeifard; Ali Zahedmehr; Rasoul Ferasatkish; Zahra Faritous; Mostafa Alavi;

Mahmoud Reza Alebouyeh; Ehsan Dehdashtian; Parisa Ziyaeifard; Zeynab Yousefi

44-50

CASE REPORT

Percutaneous Coronary Intervention and Pulmonary Balloon Valvuloplasty in a 56-Year-Old

Woman With Severe Valvular Pulmonary Stenosis: A Case Report

Ata Firouzi; Omid Shafe; Farzad Kamali; Foroozan Asgari

51-55

INSTRUCTIONS FOR AUTHORS 56-59

FORTHCOMING MEETINGS 60-63

SUBSCRIPTION FORM 64-65

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Returning CPB Blood to Patients by Head-Up Position Azarfarin R, et al

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Original Article Returning CPB Blood to Patients by Head-Up Position Azarfarin R, et al.

Efficacy of the “Head-Up Position” in Returning Cardiopulmonary

Bypass Blood to the Patient and Reducing the Required Blood

Transfusion: A Randomized Trial

Rasoul Azarfarin1, MD; Majid Dashti*

2, MD; Ziae Totonchi

3, MD;

Mohsen Ziyaeifard 3, MD; Mohamadjavad Mehrabanian

3, MD;

Azin Alizadehasl 1, MD; Farhad Gorjipour

3, MS

ABSTRACT

Background: All intraoperative strategies that may assist an anesthesiologist with lowering the

blood transfusion rate must be considered. We assessed the efficacy of the 30° head-up

position at the end of cardiopulmonary bypass (CPB) in returning CPB reservoir blood to

patients, reducing the transfusion rate, and conferring hemodynamic stability after the

transfer of patients to the intensive care unit (ICU).

Methods: In a single-center clinical trial, 88 adult patients undergoing elective isolated coronary

artery bypass graft surgery were randomly allocated to the head-up group (n=44), in which

the 30° head-up position was applied during separation from CPB, and the supine group

(n=44), in which weaning from CPB was performed in the supine position. All the patients

had left ventricular ejection fractions > 35%. The primary end point was the returned

volume of filtered CPB blood to the patients. The secondary outcome measures were

intraoperative and early postoperative hemodynamic parameters. Additionally, blood

products transfused during surgery and in the 1st 6 hours following ICU admission were

recorded.

Results: There were no statistically significant differences in intraoperative and early postoperative

hemodynamics between the 2 groups except in the returned blood volume to the patients

after separation from CPB (714 ± 99 mL in the head-up position group vs 285 ± 78 mL in

the supine group; P = 0.0001). There were no significant differences between the 2 groups

regarding the transfused blood products during surgery and the 1st 6 hours following ICU

admission.

Conclusions: Using the 30° head-up position at the end of CPB conferred a higher return of blood

to the patients but did not significantly reduce postoperative transfusion. (Iranian Heart

Journal 2017; 18(1):6-15)

Keywords: Supine position, Coronary artery bypass surgery, Cardiopulmonary bypass,

Blood transfusion, Hemodynamics

1 Echocardiography Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran. 2 Department of Anesthesiology, Sadoughi University of Medical Sciences, Yazd, I.R. I.R. Iran. 3 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.

*Corresponding Author: Majid Dashti MD, Anesthesiology Department, Sadoughi University of Medical Sciences, Yazd, I.R. Iran.

E-mail: [email protected] Tel: 0983535239976

Received: June 8, 2016 Accepted: October 10, 2016


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he role of anesthesiologists in the

perioperative management of patients

undergoing coronary artery bypass

grafting surgery (CABG) is expanding. 1

Anesthesiologists must be expert not only in

performing safe anesthesia techniques but

also in providing all aspects of perioperative

care for ischemic heart disease patients. In

order to achieve better outcomes, they must

consider developments in pharmacological

materials and instruments, new surgical

techniques, anesthesia management, and

monitoring techniques. 1 Although due to the

emergence of percutaneous interventions, the

number of the patients referred for CABG is

reducing, coronary artery disease is still

accounts for 1 of 6 deaths in the United

States. 2, 3

It has been reported that 40%–70% of all red

blood cell units are transfused throughout

surgical procedures. 4, 5

A reduction in only 1

unit of the transfused blood products has been

reported to lessen mortality and morbidity;

therefore, all intraoperative strategies that

may help an anesthesiologist with lowering

the blood transfusion rate must be considered. 6, 7

Some interventions can lower the required

homologues blood transfusion volume; they

include controlled hypotension, acute

normovolemic hemodilution, autologous

blood predonation, relative reduction of target

hematocrit for transfusion, optimal surgical

homeostasis, reducing cardiopulmonary

bypass (CPB) time, ultrafiltration during CPB,

and finally returning the remaining volume of

reservoir and the tubing system just before

aortic decannulation at the end of CPB. Stress

response to surgery can be modified through

surgical method and patient position. 8

Hypotension and ventricular dysfunction are

prevalent perioperative hemodynamic

abnormalities in cardiac surgeries. 9, 10

In post-

CABG patients undergoing low tidal volume

mechanical ventilation, stroke volume

variation can predict responsiveness to

volume therapy and can assess its

hemodynamic effects. 11

Recently, dynamic

changes in preload such as pulse pressure

variation have been reported to be due to

cyclic variations in stroke volume during

mechanical ventilation by cardiopulmonary

interaction. 12

Also, dynamic variables of

preload are important in directing fluid and

inotrope therapy in critically ill patients. 13

Supine position is the commonest position in

surgery; hemodynamic reserve is best

maintained in this position as the whole body

is almost at cardiac level. The compensatory

mechanisms of hemodynamic changes are

blunted during anesthesia and only a few

degrees of head-up or head-down position is

enough to produce significant cardiovascular

changes. 14

In the present study, we proposed that some

volume of CPB reservoir blood could be

pooled to the splanchnic veins and the lower

extremity of patients by using the 30° head-up

position at the end of CPB through blunting

the autonomic nervous system and vascular

autoregulation. Before the transport of

patients, their position is returned to supine to

allow some autotransfusion of pooled blood

to the central circulation. Via invasive blood

pressure and central venous pressure (CVP)

monitoring, as well as monitoring the arterial

blood gas and lactate levels, we ensured the

return of adequate cardiac preload and

avoided overloading the patients. The aim of

this blood volume return to the patients was to

reduce the rate of homologous blood

transfusion after separation from CPB and to

prevent hypotension in the early post- CABG

period.

METHODS

The research proposal was approved by the

institutional ethics committee. Written

informed consent was obtained from all the

patients. In this single-blind clinical trial, 88

patients (aged between 40 and 60 years) who

underwent elective isolated CABG were

recruited. All the patients had left ventricular

ejection fractions > 35%, were weaned from

CPB, and had acceptable arterial blood gas,

T

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hemoglobin, and electrolyte profiles.

Whitlock et al 14

returned a mean of 280 mL

of processed blood from CPB to their

patients. We hypothesized a 100-mL

difference in the retuned blood volume by

applying the head-up position at the end of

CPB. Considering an α of 0.05 and a β of 0.1

and by using an online sample size calculator

(http://www.stat.ubc.ca/~rollin/stats/ssize/n2.

html), we calculated that each group was to

comprise 44 patients. The patients were

randomly allocated to 2 groups of head-up

(n=44) and supine (n=44) by using online

software(http://www.graphpad.com/quickcalc

s/randomize2/). The randomization list was

kept concealed by the head of the

anesthesiology department. The participants

were entered in the study and assigned to the

head-up and supine groups sequentially.

Intraoperative monitoring—including left

radial arterial line; systolic, diastolic, and

mean arterial pressures; CVP via the right

internal jugular vein; ECG; and airway

pressure—was performed in both groups. In

23 patients in the head-up group and 21

patients in the supine group, we planned to

use a pulmonary artery catheter (PAC) to

monitor the cardiac output (CO) during

surgery. After the induction of anesthesia, a

7.0-Fr PAC (Swan-Ganz CCO/VIP PAC,

Edwards Lifesciences) was placed via the

right internal jugular vein and connected to a

VigilanceTM

monitor (Version 6.3, Edwards

Lifesciences).

The anesthetics and techniques were the same

in all the patients. The surgical methods of

coronary revascularization and CPB priming

and technique were similar in both study

groups. The only difference between the 2

groups was the 30° head-up at the end of CPB

in the head-up group. Returning the volume

of the tubing system and the reservoir of the

CPB circuit to the patients was continued

until a target CVP of 10–12 mm Hg was

achieved. Subsequently, aortic decannulation

was performed and the patients’ position was

changed to supine at the end of surgery before

transfer to the intensive care unit (ICU). All

the hemodynamic parameters and total blood

products (packed red blood cell, fresh frozen

plasma, and platelet) transfused

intraoperatively and within the 1st 6 hours

following ICU admission were recorded.

Statistical Analysis

There was no loss to follow-up in the course

of the present study. Intention-to-treat

statistical analysis was utilized. The collected

data were analyzed using IBM SPSS for

Windows, version 21.0 statistical package

(IBM SPSS Inc, Chicago, IL, USA). The

Kolmogorov–Smirnov test was used to

evaluate the adaptation of the collected data

with normal distributions. The qualitative data

were analyzed using the χ2 test or the Fisher

exact test, and the quantitative parameters

were analyzed using the independent samples

t-test. A P value ≤ 0.05 was considered

statistically significant.

RESULTS

Eighty-eight patients, at a mean age of 58.3 ±

5.9 years old, were studied. All the data were

normally distributed according to the

Kolmogorov–Smirnov test (all P values >

0.05). The patients were similar in both

groups with respect to their demographic and

background characteristics (Table 1).

There were no significant differences in

intraoperative and early postoperative

variables between the 2 groups, except in the

returned blood volume to the patients after

separation from CPB (714 ± 99 mL in the

head-up group vs 285 ± 78 mL in the supine

group; P = 0.0001) and the remaining volume

in the CPB circuit (128 ± 95 vs 523 ± 125

mL, respectively; P = 0.00010) (Table 2). In

both studied groups, the crystalloid fluids

administered by the anesthesiologist or added

by the surgery team were similar. The

intraoperative urine output was not

significantly different between the 2 groups.

Totally, 30/88 (34%) of our CABG patients

received packed red blood cells (PRBCs)

http://www.stat.ubc.ca/~rollin/stats/ssize/n2.html

http://www.stat.ubc.ca/~rollin/stats/ssize/n2.html

http://www.graphpad.com/quickcalcs/randomize2/

http://www.graphpad.com/quickcalcs/randomize2/

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during surgery or in the early postoperative

period. Also, there were no significant

differences between the 2 groups in terms of

the transfusion of blood and blood products in

the intraoperative period and in the 1st 6

hours following ICU admission (Table 3).

Table 1. Basic characteristics of the patients undergoing CABG with or without applying the 30º

head-up position after separation from CPB

Head-Up Group (n=44)

Supine Group (n=44)

P

Age (y) 59.1±6.3 57.4±5.5 0.214

Sex (male) 36(85.7%) 31(73.8%) 0.277

Height (cm) 167±8.0 166±8.9 0.766

Weight (kg) 73.8±10.0 75.1±9.3 0.537

BSA (m2) 1.81±0.14 1.85±0.13 0.363

Diabetes mellitus 20(47.6%) 22(52.4%) 0.827

Hypertension 26(61.2%) 25(59.5%) 0.823

COPD* 5(11.9%) 6(14.3%) 0.746

LVEF (%)* 47.3±5.7 46.6±6.3 0.589

Blood urea nitrogen (mg/dL) 19.3±6.8 19.0±6.0 0.215

Creatinine (mg/dL) 0.96±0.25 0.89±0.27 0.866

MR*severity (none, mild/moderate/severe)

33/8/1 31/11/0 0.464

TR*severity (none, mild/moderate/severe)

37/5/0 30/12/0 0.057

CABG, Coronary artery bypass graft surgery; CPB, Cardiopulmonary bypass; COPD, Chronic obstructive pulmonary disease; LVEF, Left ventricular ejection fraction; MR, Mitral regurgitation; TR, Tricuspid regurgitation

Table 2. Intraoperative and postoperative variables of the patients undergoing CABG with or without applying

the 30º head-up position after separation from CPB


Supine Group (n=42)

P

CPB time (min) 83.5±30.5 84.6±23.9 0.861

Aortic cross-clamp (min) 47.0±21.7 48.1±15.9 0.815

Coronary graft No. (mean) 3.17±0.85 3.05±0.66 0.477

Crystalloid administered by the anesthesiologist (mL) 2200±588 2032±456 0.148

Crystalloid added to the field by the surgery team (mL) 2588±652 2630±367 0.712

CPB prime and added volume (mL) 2786±825 2754±492 0.829

Waste suction volume (mL) 1032±382 1007±300 0.740

Filtered volume (by the perfusionist) (mL) 1154±845 1163±854 0.964

Returned volume to the patient after separation from CPB (mL) 714±99 285±78 0.0001

Remaining volume in the CPB circuit (mL) 128±95 523±125 0.0001

CO after the induction of anesthesia (liter/min) 4.7±1.1 (n=23) 4.6±1.2 (n=21) 0.744

CO at the end of CPB before the return of the residual volume (liter/min) 4.9±1.3 (n=23) 4.8±1.3 (n=21) 0.800

CO at the end of CPB after the return of the residual volume (liter/min) 5.5±1.6 (n=23) 5.2±1.4 (n=21) 0.513

Intraoperative urine volume (mL) 1319±542 1135±429 0.090

Intraoperative furosemide (mg) 5.9±3.8 4.8±2.9 0.436

Intraoperative inotrope use 21.4% 17.1% 0.549

Postoperative inotrope use 7.1% 14.3% 0.374

* CABG, Coronary artery bypass graft surgery; CPB, Cardiopulmonary bypass; CO, Cardiac output

Table 3. Transfused units of blood and blood products in the patients undergoing CABG with or without

applying the 30º head-up position after separation from CPB


Supine Group (n=44)

P

Intraoperative Packed RBC* [0/1/2/more] (units) 27/15/0/0 27/12/1/2 0.504

FFP* [0/1/2/more] (units) 38/1/4/2 39/0/2/1 0.384

Platelets [0/1/2/more] (units) 33/2/5/2 40/0/2/0 0.114

Early ICU Packed RBC [0/1/2/more] (units) 25/13/3/1 29/8/3/2 0.344

FFP [0/1/2/more] (units) 33/1/6/2 36/1/5/0 0.315

Platelets [0/1/2/more] (units) 35/2/4/1 37/3/2/0 0.589

RBC, Red blood cell; FFP, Fresh frozen plasma

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Figure 1 demonstrates the variations of

systolic and diastolic blood pressures and the

heart rate in both study groups. There were no

significant differences in hemodynamics

between the head-up and supine groups. As

Figure 2 shows, the patients’ PaO2 decreased

from the end of CPB to the ICU admission. It,

however, remained at clinically acceptable

levels. There were no statistically significant

differences between the 2 groups regarding

the PaO2 or PaCO2 levels during the study

period. Figure 3 shows that serum lactate

levels slightly deceased and the base deficit

increased slightly during CABG. However,

their levels were not altered to the levels to be

considered harmful to the patients. There

were no significant differences between the 2

groups regarding these parameters. The

patients’ hematocrit and hemoglobin levels

decreased during CPB in acceptable degrees

and returned to clinically acceptable values in

the ICU, without significant differences

between the 2 groups (Fig. 4).

We also recorded the patients’ CVP and the

mean airway pressure during surgery and up

to 1 hour after admission to the ICU. There

were minimal changes in airway pressure in

both groups. The mean CVP in both groups

decreased at the end of CPB (to about

4 mmHg), but returned to about 8 mm Hg and

increased up to 10 mm Hg 1 hour after

admission to the ICU (Fig. 5).

40

50

60

70

80

90

100

110

120

130

140 Head UP Group SBPControl Group SBPHead Up Group HRControl Group HRHead UP Group DBPControl Group DBP

Figure 1. Hemodynamic variations of the patients undergoing coronary artery bypass graft surgery with or without

applying the 30º head-up position after separation from CPB. CPB, Cardiopulmonary bypass

050

100150200250300

Head UP Group PaO2

Figure 2. Arterial blood gas fluctuations of the patients undergoing coronary artery bypass graft

surgery with or without applying the 30º head-up position after separation from CPB. CPB, Cardiopulmonary bypass

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Figure 3. Acid-base variations of the patients undergoing coronary artery bypass graft surgery

with or without applying the 30º head-up position after separation from CPB. CPB, Cardiopulmonary bypass

Figure 4. Blood levels of hemoglobin and hematocrit in the patients undergoing coronary artery

bypass graft surgery with or without applying the 30º head-up position after separation from CPB. CPB, Cardiopulmonary bypass

Figure 5. Mean airway and central venous pressures of the patients undergoing coronary artery bypass

graft surgery with or without applying the 30º head-up position after separation from CPB. CPB, Cardiopulmonary bypass

7

12

17

22

27

32

37

42

Head UP Group Hemoglobin(mg/dl)

Control Group Hemoglobin(mg/dl)

Head Up Group Hematocrit(%)

Control Group Hematocrit(%)

02468

10121416

Head UP Group Mean airway pressure

Control Group Mean airway pressure

Head Up Group Central venous pressure

Control Group Central venous pressure

-6

-4

-2

0

2

4

6Head UP Group PH

Control Group PH

Head Up Group Lactate

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DISCUSSION

We hypothesized that retuning more filtrated

CPB residual blood volume to patients by

applying head-up positioning at the end of

CPB and then re-directing the pooled blood of

the splanchnic veins and the lower extremities

to the central circulation by returning the

patients to supine position during their

transfer to the ICU could prevent

hypovolemia and hypotension and also, this

“autotransfusion” might reduce the need to

homologous transfusion in the postoperative

period.

We succeeded in returning a mean value of

429 mL of filtered (processed) blood to our

patients after separation from CPB through

the application of the 30º head-up position.

Although this return volume is clinically

significant, we could not find any significant

differences in hemodynamic parameters

(blood pressure or the CO) and also in the

number of the required blood product units

between the 2 study groups.

Institutions vary considerably in their

transfusion practices for CABG. 15

In a study

performed by Stover at al, 15

a substantial

variability (27%–92%) in transfusion practice

was observed in institutions for PRBCs.

Elsewhere, Lokosky et al 16

found that the

transfusion of small (1–3) units of PRBCs

was common, yet different, across geographic

areas. The authors posited that differences in

regional practice, consisting of transfusion

triggers and perioperative anemia

management, might affect variability in the

transfusion rates of PRBCs. Other

investigators have also presented similar

findings on the institutional variability of

transfusion practice. 17-19

On the other hand, it seems that there is also a

significant variability in transfusion practice

among surgeons and also among

anesthesiologists within a single institution.

Frank et al 20

reported a significant

discrepancy in this regard among surgical

services and techniques, and also among

individual surgeons and anesthesiologists.

The use of the RBC salvage technique, fresh

frozen plasma, and platelets varied 3-4 times

among individual surgeons compared with

their colleagues carrying out the same surgical

technique. In the present study, the surgical

operations were performed by 7 different

surgeons and 6 anesthesiologists. Given the

significant individual variability in

transfusion practice among our hospital’s

surgeons and anesthesiologists, this powerful

confounding factor may have overcome small

differences in blood-saving properties via the

application of the head-up position and the

return of the reservoir blood to the patients at

the end of CPB in our intervention group.

Some studies have demonstrated the

beneficial effects of returning the

hemoconcentrated residual CPB volume to

patients on biochemical and clinical patient

outcomes in the postoperative period but not

on either coagulation parameters or

postoperative bleeding following cardiac

surgery. 21, 22

Daane et al 23

suggested that

processing and transfusing the residual CPB

volume had no effects on complement

activation, hemostasis, or the postoperative

blood loss and volume of transfusion in their

cardiac surgery patients. As was previously

mentioned, various techniques are used to

return the CPB residual blood to patients with

different laboratory and clinical results. In our

study, we sought to demonstrate the new

technique of the head-up position so as to

redistribute the venous and splanchnic blood

to the lower body segments and to allow the

return of the CPB residual blood to the

patients at the end of CPB. On average, we

managed to return 400 mL of filtered and

hemoconcentrated residual CPB blood to our

patients; however, this technique failed to

show any beneficial effects on postoperative

hematocrit levels or needs for transfusion in

our patient population.

In 2013, Bubenek-Turconi et al 24

compared 2

methods of measuring the CO (ie,

noninvasive Nexfin [NAPCO] and PAC) in

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cardiac surgical patients before and after

preload-modifying maneuvers, including fluid

challenge or passive leg-raising maneuver.

Both methods reliably showed preload-

induced changes in the CO in the stable

patients. We used continuous CO monitoring

using PAC in nearly half of our patients.

Although a small increase was observed in the

head-up group, in comparison with the supine

group, we could not find any significant

increase in the CO by returning more residual

CPB reservoir blood volume to the patients

after separation from CPB. The small sample

size of the study might have contributed to the

absence of any statistically significant

increase in the CO in the head-up group after

CPB.

CONCLUSIONS

In this single-center clinical trial, through the

application of the 30º head-up position, a

mean value of 429 mL of filtered (processed)

blood was returned to the CABG patients

after separation from CPB. This volume

return, despite being clinically significant,

was statistically insignificant. Additionally,

no significant differences were observed in

the hemodynamic parameters (blood pressure

and the CO) and also in the number of

required blood product units between the 2

study groups.

Limitations

This trial was a single-center study,

performed on 88 CABG patients, which limits

its generalizability. Further, we succeeded in

measuring the CO only in 23 patients in the

head-up group and 21 patients in the supine

group. This lowers the study’s power

regarding advanced hemodynamic monitoring

to assess effects of the head-up position at the

end of CPB. In our study, the patients

underwent surgery by 7 different surgeons

and 6 different anesthesiologists. Regarding

the significant individual variability in

transfusion practice among our hospital’s

surgeons and anesthesiologists, this powerful

confounding factor might have contributed to

small differences in blood-saving properties

through the application of the head-up

position and the return of the reservoir blood

to the patients at the end of CPB in our

intervention group.

ACKNOWLEDGEMENTS

We hereby thank the staff and perfusionists of

the operating rooms at Rajaie Cardiovascular,

Medical, and Research Center for their

assistance with the management of the

patients. This research project was supported

by the aforementioned center.

Conflict of Interest: The authors declare no

conflict of interest. This study was financially

supported by Rajaie Cardiovascular, Medical,

and Research Center, Iran University of

Medical Sciences, Tehran, Iran.

-

REFERENCES

1. Glance LG1, Kellermann AL, Hannan EL,

Fleisher LA, Eaton MP, Dutton RP, Lustik SJ,

Li Y, Dick AW. The Impact of

Anesthesiologists on Coronary Artery Bypass

Graft Surgery Outcomes. Anesthesia &

Analgesia March 2015; 120 (3): 526–533.

2. Lloyd-Jones D, Adams RJ, Brown TM,

Carnethon M, Dai S, De Simone G, Ferguson

TB, Ford E, Furie K, Gillespie C, Go A,

Greenlund K, Haase N, Hailpern S, Ho PM,

Howard V, Kissela B, Kittner S, Lackland D,

Lisabeth L, Marelli A, McDermott MM,

Meigs J, Mozaffarian D, Mussolino M, Nichol

G, Roger VL, Rosamond W, Sacco R, Sorlie

P, Roger VL, Thom T, Wasserthiel-Smoller S,

Wong ND, Wylie-Rosett J; American Heart

Association Statistics Committee and Stroke

Statistics Subcommittee. Heart disease and

stroke statistics. 2010 update: a report from

the American Heart Association. Circulation.

2010 Feb 23;121(7):e46-e215.

3. Miniño AM, Heron MP, Smith BL:

Preliminary data for 2004. Nat Vital Stat Rep

2006; 54(19):1-49.

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4. Wells AW1, Mounter PJ, Chapman CE,

Stainsby D, Wallis JP. Where does blood go?

Prospective observational study of red cell

transfusion in north England. BMJ. 2002 Oct

12; 325(7368):803.

5. Patel MS, Carson JL. Anemia in the

Preoperative Patient. Med Clin North Am.

2009 September; 93(5): 1095–1104.

6. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI,

Culliford L, Angelini GD. Increased mortality,

postoperative morbidity, and cost after red

blood cell transfusion in patients having

cardiac surgery. Circulation. 2007;

116(22):2544–52.

7. Alizadeh-Ghavidel A, Totonchi Z, Hoseini A,

Mohsen Ziyaeifard M, Azarfarin R. Blood

Transfusion Practice in a Referral

Cardiovascular Center in Tehran, Iran: A

Critical Point of View. Res Cardiovasc Med.

2014 Oct 14;3(4):e21772.

8. Cortizer TA, Muller JE, Quittkat D, Sydow

M, Wuttke W, Kettler D. Effect of anesthesia

on the cytokine responses to abdominal

surgery. British journal of anesthesia. 1994,

72: 280- 285.

9. Bendijelid K, Romand JA. Fluid

responsiveness in mechanically ventilated

patients: a review of indices used in intensive

care. Intensive Care Med 2003; 29:352-60.

10. Buda AJ, Pinsky MR, Ingels NB, Ingels NB

Jr, Daughters GT 2nd, Stinson EB, Alderman

EL. Effect of intra thoracic pressure on left

ventricular performance. N Engl J Med 1979;

301:453-9.

11. Rex S, Brose S, Metzelder S, Hüneke R,

Schälte G, Autschbach R, Rossaint R, Buhre

W. Prediction of fluid responsiveness in

patients during cardiac surgery. British

Journal of Anaesthesia. 2004; 93 (6): 782–8.

12. Reuter DA, Felbinger TW, Schmidt C, Kilger

E, Goedje O, Lamm P, Goetz AE. Stroke

volume variations for assessment of cardiac

responsiveness to volume loading in

mechanically ventilated patients after cardiac

surgery. Intensive Care Med 2002; 28:392-8.

13. Perel A. assessing fluid responsiveness by

systolic pressure variations in mechanically

ventilated patients. Systolic pressure variation

as a guide to fluid therapy in patients with

sepsis induced hypotension. Anesthesiology

1998; 89:1309-10

14. Whitlock R, Mathew J, Eikelboom J, Al-Saleh

AM, Yuan F, Teoh K. Processed residual

pump blood in cardiac surgery: the Processed

Residual Blood in Cardiac surgery trial.

Transfusion. 2013 Jul;53(7):1487-92.

15. Stover EP, Siegel LC, Parks R, Levin J, Body

SC, Maddi R, D'Ambra MN, Mangano DT,

Spiess BD. Variability in transfusion practice

for coronary artery bypass surgery persists

despite national consensus guidelines: a 24-

institution study. Institutions of the

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88(2):327-333.

16. Likosky DS, Al-Attar PM, Malenka DJ,

Furnary AP, Lehr EJ5, Paone G, Kommareddi

M, Helm R, Jin R, Maynard C, Hanson EC,

Olmstead EM, Mackenzie TA, Ross CS,

Zhang M. Geographic variability in

potentially discretionary red blood cell

transfusions after coronary artery bypass graft

surgery. J Thorac Cardiovasc Surg. 2014 Dec;

148(6):3084-9.

17. Maddux FW1, Dickinson TA, Rilla D,

Kamienski RW, Saha SP, Eales F, Rego A,

Donias HW, Crutchfield SL, Hardin RA.

Institutional variability of intraoperative red

blood cell utilization in coronary artery bypass

graft surgery. Am J Med Qual. 2009 Sep-

Oct;24(5):403-11.

18. McQuilten ZK, Andrianopoulos N2, Wood

EM3, Cole-Sinclair MF4, McNeil JJ2,

Cameron PA2, Reid CM2, Newcomb AE5,

Smith JA6, Phillips LE. Transfusion practice

varies widely in cardiac surgery: Results from

a national registry. J Thorac Cardiovasc Surg.

2014 May;147(5):1684-1690.e1.

19. Rogers MA, Blumberg N, Saint S, Langa KM,

Nallamothu BK. Hospital variation in

transfusion and infection after cardiac surgery:

a cohort study. BMC Med. 2009 Jul 31;7:37.

doi: 10.1186/1741-7015-7-37.

20. Frank SM1, Savage WJ, Rothschild JA,

Rivers RJ, Ness PM, Paul SL, Ulatowski JA.

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information management system.

Anesthesiology. 2012 Jul;117(1):99-106.

21. McNair E1, McKay W, Qureshi AM, Rosin

M, Gamble J, Dalshaug G, Mycyk T, Prasad

K. Outcomes and biochemical parameters

following cardiac surgery: effects of

transfusion of residual blood using

centrifugation and multiple-pass

hemoconcentration. J Cardiothorac Vasc

Anesth. 2013 Dec;27(6):1174-80.

22. Johnson HD1, Morgan MS, Utley JR, Leyand

SA, Nguyen-Duy T, Crawley DM.

Comparative analysis of recovery of

cardiopulmonary bypass residual blood: cell

saver vs. hemoconcentrator. J Extra Corpor

Technol. 1994 Dec;26(4):194-9.

23. Daane CR, Golab HD, Meeder JH, Wijers MJ,

Bogers AJ. Processing and transfusion of

residual cardiopulmonary bypass volume:

effects on haemostasis, complement

activation, postoperative blood loss and

transfusion volume. Perfusion. 2003

Apr;18(2):115-21.

24. Bubenek-Turconi SI, Craciun M, Miclea I,

Perel A. Noninvasive continuous cardiac

output by the Nexfin before and after preload-

modifying maneuvers: a comparison with

intermittent thermodilution cardiac output.

Anesth Analg. 2013 Aug;117(2):366-72.

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Results of 3 Years’ Experience in Pulmonary Embolectomy: A Single-Center Experience Moeinipour A, et al

16

Original Article Results of 3 Years’ Experience in Pulmonary Embolectomy: A Single-Center Experience Moeinipour A, et al.

Results of 3 Years’ Experience in Pulmonary Embolectomy:

A Single-Center Experience

Aliasghar Moeinipour1, MD; Mohammad Abbasi Teshnizi

1, MD;

Atefeh Ghorbanzadeh1, MD; Mohammad Sobhan Sheikh Andalibi

1, MD;

Mohamadreza Akbari1 , MD; Hamid Hoseinikhah

1*, MD

ABSTRACT

Background: Pulmonary embolism is associated with high mortality rates despite improvements in

its management. The aim of the present study was to analyze the outcome of 20 patients

who underwent surgical pulmonary embolectomy in our institution.

Methods: The medical records of all patients undergoing pulmonary embolectomy during a

3-year period at our institution were studied for demographic and preoperative data as well

as hospital mortality.

Result: Twenty patients underwent pulmonary embolectomy. The patients were aged between 35

and 76 years old. Fourteen (70%) patients were male. The most common risk factor in these

patients was a history of major surgery (55%). The hospital mortality rate was 25%.

Conclusions: Pulmonary embolectomy can be considered an effective approach in patients

with pulmonary embolism and carries low mortality and morbidity. (Iranian Heart Journal

2017; 18(1):16-19)

Keywords: Pulmonary embolectomy, Thromboembolism, Cardiac surgery

1 Department of Cardiac Surgery, Atherosclerosis Prevention Research Center, Faculty of Medical Sciences, Imam Reza Hospital, Mashhad University of Medical Sciences, I.R. Iran.

*Corresponding Author: Hamid Hoseinikhah, MD; Atherosclerosis Prevention Research Center, Faculty of Medical Sciences, Mashhad University of Medical Sciences, I.R. Iran.


Received: August 29, 2016 Accepted: December 1, 2016

enous thromboembolism (VTE) is a

relatively common disease associated with

high mortality and morbidity. 1, 2

The

incidence of VTE ranges from 75 to 269 cases per

100000 persons per annum. VTE includes deep

vein thrombosis (DVT), which mostly occurs in

the leg, thigh, or pelvis, and also its complications

such as pulmonary embolism (PE). 1

More than 90% of clinically detected pulmonary emboli are associated with lower extremity DVT,

although more than half of patients with DVT and

PE are asymptomatic.

VTE is a difficult diagnosis because its

clinical presentations are not unique. 2

Historically, the predisposing factors that lead

to DVT are termed “Virchow’s triad”, which

comprises immobility or stasis,

hypercoagulation state, and endothelial injury.

Most of the patients who suffer from DVT

V


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have a history of prolonged immobility

because of limb or pelvic fracture and major

orthopedic or abdominal surgery. Other

common reasons include malignancy,

multiple trauma, prior VTE, and chronic heart

failure. 2-4

Although VTE prophylaxis has

been shown to improve the outcome of

patients over time, PE remains the most

common cause of in-hospital death and also

the most common preventable cause of in-

hospital death. 3 Treatment options in this

condition include systemic thrombolytic

therapy, catheter-based treatments, and

surgical embolectomy. Surgical embolectomy

is a valuable lifesaving treatment in patients

who have not benefitted from fibrinolysis or

who have an absolute contraindication for

fibrinolytic therapy. 5

We analyzed the outcome of 20 patients who

underwent surgical pulmonary embolectomy

in Imam Reza Hospital, in Iran.

METHODS

We evaluated 20 patients with a documented

diagnosis of PE that underwent surgical

intervention with pulmonary embolectomy in

Imam Reza Hospital in Mashhad. The

diagnosis of PE was confirmed via

transthoracic echocardiography (TTE),

transesophageal echocardiography (TEE), and

computed tomography (CT) angiography. The

indications for surgery were instability in

hemodynamic status and respiratory

insufficiency.

RESULTS

The study population comprised 20 patients,

aged between 35 and 76 years. Fourteen

patients were male. The predisposing risk

factors that lead to DVT and PE included

major orthopedic and pelvic surgery in 6

patients and major abdominal surgery in 5. A

history of malignancy was present in 5

patients. Some types of hypercoagulation

syndrome like Pro C and Pro S deficiency

were found in 3 patients. All the patients

underwent pulmonary embolectomy with

support cardiopulmonary bypass (CPB). After

median sternotomy and opening the

pericardium, heparin was administrated and

aortic bicaval cannulation was initiated and at

the time of the procedure. After the

arteriotomy of the pulmonary artery, clot and

embolic material was removed from the main,

right, and left pulmonary arteries separately.

Following the closure of the pulmonary

artery, the aortic cross-clamp was released

and the patients were weaned from CPB. For

a successful weaning, usually inotropic

support was needed.

Out of the 20 patients in the study, 4 patients

died: 2 patients died in the operating room

(they could not be weaned from CPB and

developed severe right ventricular failure and

high pulmonary artery pressure) and the

remaining 2 patients expired in the intensive

care unit in the 1st 24 hours after the

procedure due to severe heart failure and

unstable hemodynamics status.

DISCUSSION

PE is associated with high mortality and

morbidity. An overall mortality rate of 17.4%

within 90 days (365 of 2393 deaths) was

reported by the International Cooperative

Pulmonary Embolism Registry (ICOPER).

Although there has been much advancement

in the diagnosis of PE, many cases are

asymptomatic and clinically undiagnosed. 6 In

about 90% of the cases, DVT is formed in the

lower extremities and then breaks free before

it passes through the right side of the heart

and into the pulmonary artery system. 2

According to the literature, the risk factors for

PE can be classified into 2 groups: acquired

risk factors such as major surgery, trauma,

immobility, cancer, pregnancy, oral

contraceptives, obesity, old age and

anticardiolipin antibodies and continuation of

primary hypercoagulation state. 4, 6

All

hospitals have documented programs for the

prevention of PE. Earlier mobilization of bed-

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rest patients after any type of surgery,

especially orthopedic and pelvic and major

abdominal surgery, should be borne in mind.

Heparin at a prophylactic dose is

administrated for some high-risk patients like

those with hypercoagulation state and those

with a history of malignancy. The

administration of subcutaneous low molecular

weight heparin, fondaparinux, and

unfractionated heparin is considered the initial

standard therapy in hemodynamically stable

patients with PE. 2, 7

Thrombolytic therapy

should be performed as 1st-line treatment in

patients with massive PE with circulatory

shock or persistent hemodynamic instability.

A meta-analysis compared thrombolytic

therapy with heparin and showed benefits in

high-risk cases, especially in patients with

massive pulmonary emboli who presented

with hemodynamic instability. It is, however,

not recommended in unselected patients

because it can increase the risk of bleeding

and intracranial hemorrhage. 8, 9

Many

antithrombotic drugs such as streptokinase,

urokinase, and tissue plasminogen activator

are available and can be used with varying

degrees of success. This type of agents, albeit

unable to prevent new clot formation, can

remove the existing clot in the pulmonary

vasculature. 8

Recently, there has been a trend toward

nonoperative management in most cases of

clinical PE. After the initiation of

anticoagulation with heparin, an

antithrombotic agent is used for the lysis of

the exiting embolic material in the pulmonary

vasculature. For every patient with

contraindications for anticoagulant

administration or recurrence of PE, some

prophylactic devices like the inferior vena

cava filter can be inserted; however, it does

not affect the free-floating proximal DVT. 7

Although the uses and benefits of this

modality are not clearly defined, the analysis

from the ICOPER showed a substantial

reduction in the mortality rate in 3 months

with inferior vena cava filters. 6

At present, the only absolute indications for

cardiac surgery intervention in cases of PE are

hemodynamic instability, respiratory failure,

contraindications to anticoagulation, and

failure of thrombolysis. In most of these

cases, there is massive saddle PE. 10, 11

Hospital mortality rates for pulmonary

embolectomy vary greatly and depend on

hemodynamic condition at the time of

surgery. Recently, improvements in surgical

techniques and perioperative care as well as

proper patient selection have conferred a

reduction in the mortality rate. 12

A cohort

study by Kilic et al 13

demonstrated a

mortality rate of 27.2% after pulmonary

embolectomy. Elsewhere, Keeling and

colleagues 14

reviewed data from the local

Society of Thoracic Surgeons’ database,

which comprised 44 patients, and reported a

significant improvement in morbidity and

mortality rates (2.3% mortality in a 30-day

period). In our study, in-hospital death

occurred in 4 (25%) patients. Elsewhere, the

mortality rates ranged from 23% to 40%, with

the rate being lower among the stable

patients. 15

CONCLUSIONS

Pulmonary embolectomy can be deemed an

effective approach in patients with PE and

carries low mortality and morbidity.

Conflict of Interest: None declared.

REFERENCES

1. Konstantinides SV, Barco S, Lankeit M,

Meyer G. Management of pulmonary

embolism: an update. Journal of the American

College of Cardiology. 2016;67(8):976-90.

2. Lapner ST, Kearon C. Diagnosis and

management of pulmonary embolism. BMJ.

2013;346(1):f757.

3. Anderson FA, Spencer FA. Risk factors for

venous thromboembolism. Circulation.

2003;107(23 suppl 1):I-9-I-16.

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4. Caprini JA, Biegler L, McCormick R. Update

on risk factors for venous thromboembolism.

The American Journal of medicine. 2005.

5. Edelman J, Okiwelu N, Anvardeen K, Joshi P,

Murphy B, Sanders L, et al. Surgical

Pulmonary Embolectomy: Experience in a

Series of 37 Consecutive Cases. Heart, Lung

and Circulation. 2016.

6. Bĕlohlávek J, Dytrych V, Linhart A.

Pulmonary embolism, part I: Epidemiology,

risk factors and risk stratification,

pathophysiology, clinical presentation,

diagnosis and nonthrombotic pulmonary

embolism. Experimental & Clinical

Cardiology. 2013;18(2):129.

7. Kucher N, Goldhaber SZ. Management of

massive pulmonary embolism. Circulation.

2005;112(2):e28-e32.

8. Wan S, Quinlan DJ, Agnelli G, Eikelboom

JW. Thrombolysis compared with heparin for

the initial treatment of pulmonary embolism a

meta-analysis of the randomized controlled

trials. Circulation. 2004;110(6):744-9.

9. Torbicki A, Perrier A, Konstantinides S,

Agnelli G, Galiè N, Pruszczyk P, et al.

Guidelines on the diagnosis and management

of acute pulmonary embolism. European heart

journal. 2008;29(18):2276-315.

10. Yavuz S, Toktas F, Goncu T, Eris C, Gucu A,

Ay D, et al. Surgical embolectomy for acute

massive pulmonary embolism. International

journal of clinical and experimental medicine.

2014;7(12):5362.

11. Neely RC, Byrne JG, Gosev I, Cohn LH,

Javed Q, Rawn JD, et al. Surgical

embolectomy for acute massive and

submassive pulmonary embolism in a series of

115 patients. The Annals of thoracic surgery.

2015;100(4):1245-52.

12. Marshall L, Mundy J, Garrahy P, Christopher

S, Wood A, Griffin R, et al. Surgical

pulmonary embolectomy: mid‐term outcomes.

ANZ journal of surgery. 2012;82(11):822-6.

13. Keeling WB, Leshnower BG, Lasajanak Y,

Binongo J, Guyton RA, Halkos ME, et al.

Midterm benefits of surgical pulmonary

embolectomy for acute pulmonary embolus on

right ventricular function. The Journal of

thoracic and cardiovascular surgery. 2016.

14. Kilic A, Shah AS, Conte JV, Yuh DD.

Nationwide outcomes of surgical

embolectomy for acute pulmonary embolism.

The Journal of thoracic and cardiovascular

surgery. 2013;145(2):373-7.

15. Stein PD, Matta F. Case fatality rate with

pulmonary embolectomy for acute pulmonary

embolism. The American journal of medicine.

2012;125(5):471-7.

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Comparison of Serum Prolactin Levels Between the Acute Phase of Heart Failure and After GDMT Shiokhi Ahmad Abad F, et al

20

Original Article Comparison of Serum Prolactin Levels Between the Acute Phase of Heart Failure and After GDMT Shiokhi Ahmad Abad F, et al

Comparison of Serum Prolactin Levels Between the Acute Phase of

Heart Failure and After Guideline-Directed Medical Therapy

Fatemeh Shiokhi Ahmad Abad 1, MD; Ahmad Amin

*1, MD; Roya Rezai

1, MD;

Maryam Mofidi Astaneh1, MD; Akram Nakhaie Amrodi

1, MD;

Nasim Naderi1, MD; Sepide Taghavi

1, MD

ABSTRACT

Background: Prolactin (PRL) has increasingly been recognized to play a stimulatory role in

inflammatory response. Recently, studies have reported an increase in the PRL level among

patients with chronic heart failure (HF); however, there are conflicting data about its role as

a prognostic factor in these patients. We aimed to measure the PRL level in the acute phase

of HF and the post guideline-directed medical therapy (GDMT) of HF to clarify whether

PRL is an acute-phase reactant or more than an acute phase-reactant in patients with HF.

Methods: The serum PRL level was assessed in 94 patients with HF in the acute phase of HF

decompensation and post-GDMT of HF. Serum N-terminal pro-brain natriuretic peptide,

high-sensitive C-reactive protein, 6-minute walk test, erythrocyte sedimentation rate, CRP,

blood urea nitrogen, creatinine, serum sodium, and white blood cell count were also

measured. Our secondary end points were mortality, transplantation, and hospitalization due

to acute HF. All the patients were followed up for 6 months.

Results: The mean serum PRL level in the acute phase was 31.3 ng/mL, which was significantly

higher than the normal reference values (4.04–15 ng/mL) (P < 0.001). The mean serum PRL

level before discharge was 34.84 ng/mL, which was significantly higher than the normal

reference values and similar to the acute phase values. The mean PRL level in the patients

with dilated cardiomyopathy was 33.61 ng/mL in the acute phase and 43.15 ng/mL after the

GDMT of HF. The mean PRL level in the patients without dilated cardiomyopathy was

33.42 ng/mL in the acute phase and 29.92 ng/mL before discharge. The mean PRL level in

the patients with re-admission was higher (27.7 ng/mL in the acute phase and 29.7 ng/mL

before discharge in the patients with no re-admission and 37.4 ng/mL in the acute phase and

42.5 ng/mL before discharge in the patients with re-admission).

Conclusions: In 57% of the patients, the mean level of PRL increased after treatment. The level

remained unchanged in 3.5% of the patients and had a drop in 39.2%. Our findings suggest

that PRL may be more than an acute-phase reactant alone. Larger studies are needed to

further elucidate the role of PRL in patients with HF. Research regarding the treatment of

patients suffering from HF with high levels of PRL post-GDMT of HF with bromocriptine

may have consequences like those in peripartum cardiomyopathy. (Iranian Heart Journal

2017; 18(1):20-24)

Keywords: Hyperprolactinemia, Cardiomyopathy, Peripartum

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1 Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R. Iran.

*Corresponding Author: Ahmad Amin, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,

I.R. Iran. E-mail: [email protected] Tel: 09128098713

Received: October 2, 2016 Accepted: January 20, 2017

eart failure (HF), a major cause of

morbidity and mortality throughout the

world, is responsible for a high rate of

hospitalization and is a principal complication

of all forms of heart diseases. Although the

results of extensive investigations in this field

have a great role in understanding THE HF

pathophysiology and better management of

patients, the prognosis of this disorder

remains poor. 1, 2

The pathophysiology of HF is closely

associated with neuroendocrine changes. The

activation of neuroendocrine systems

contributes to the progression of HF. Many

neuroendocrine factors are changed in

congestive HF. Not only are the

neuroendocrine changes a marker of the

severity of cardiac dysfunction, but also they

directly worsen it. The cornerstone of HF

therapy is modulating these neuroendocrine

changes and decreasing their adverse

effects.4-6

Prolactin (PRL), mainly its 16-kDa

angiostatic and proapoptotic form, is a key

factor in the pathophysiology of peripartum

cardiomyopathy (PPCMP). Previous reports

have suggested that bromocriptine may have

beneficial effects in women with the acute

onset of PPCMP. 3

Serum PRL is associated with neuro-

hormonal/immune activation and depressive

symptoms and is an independent predictor of

prognosis in advanced congestive HF.

The aim of this study was to assess the PRL

level in patients admitted with acute HF and

post guideline-directed medical therapy

(GDMT) with a view to assessing whether or

not PRL has an acute-phase reactant role.

METHODS

Study Participants

A total of 94 patients with the diagnosis of HF

according to the European Society of

Cardiology’s Guidelines 1 admitted to our

Heart Failure Clinic between June and March

2014 were enrolled. The inclusion criteria

were ischemic cardiomyopathy and dilated

cardiomyopathy (DCM) in patients with a left

ventricular ejection fraction (LVEF) < 50%

and New York Heart Association (NYHA)

functional classes II–IV.

Patients had to be on standard HF therapy

with diuretics and neurohormonal blockers

according to the latest guidelines on HF

management. 1 The study population was

subsequently followed up for 6 months.

Hospitalization due to acute HF,

transplantation, and death were also

registered. No patient was lost during the

follow-up, and HF medications were not

changed unless an expected event occurred.

Data acquisition and laboratory

measurements

Primary evaluation, clinical history, and

physical examination were obtained from all

the patients, and the demographic data and the

NYHA classifications were recorded. The

NYHA class was evaluated, whereby class I

indicated no limitations of physical activity,

class II indicated slight limitation of physical

activity, class III indicated limitation of

physical activity, and finally class IV

indicated symptoms of dyspnea at rest. 1 The

exercise tolerance and functional performance

of the patients were assessed via the 6-minute

walk test (6MWT) according to the protocol

of Guyatt and colleagues. 8

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The levels of N-terminal pro-brain natriuretic

peptide (NT-proBNP) for neurohormonal

status 9-11

and high-sensitive C-reactive

protein (hs-CRP) as a pro-inflammatory

marker 7,10

have been recognized as important

quantitative plasma biomarkers for the

development of prognostic tools for idiopathic

dilated cardiomyopathy. Peripheral blood

samples were collected for NT-proBNP

analysis using the ELISA method (BioMedia

Corp, Bratislava, Slovakia). Serum hs-CRP

levels were measured via the slide

agglutination method and

immunoturbidimetry using an hs-CRP latex

kit (Bionic, USA) for each sample. Serum

PRL was measured via the 2-site

immunoradiometric assay (IRMA) (Pathan,

Iran). The reference range was 4.04–15.2

ng/mL. Thyroid-stimulating hormone (TSH)

was also measured through

radioimmunoassay (Autobio, China) in all the

patients with a reference range of 0.27–4.2

mU/mL. All the blood samples were collected

from the patients in a fasting state and sitting

position, an hour after awakening from an

overnight sleep.

After GDMT and before discharge, the

aforementioned biomarkers (especially PRL)

were checked again to compare their pre- and

post-treatment levels.


IBM SPSS Statistics 19.0 for Windows (IBM

Corp. Armonk, NY, USA) was used for the

statistical analysis. The data are expressed as

mean ± standard deviation (SD) for the

interval and count (percent) for the categorical

variables. The one-Sample Kolmogorov–

Smirnov test was used to test the normal

distribution of the interval variables. The one-

sample t-test was employed to analyze

differences in the mean values of hormonal

concentrations between the patients and the

normal reference values and between the pre-

and post-treatment values. The interval

variables were compared between the 2

groups using the Student t-test (for the

normally distributed data) or its non-

parametric equivalent, the Mann–Whitney U-

test (for the non-normally distributed data).

The Pearson correlation coefficient (r) was

also utilized to show linear correlations

between the interval variables. A P value <

0.05 was considered significant. A logistic

regression model was applied for

multivariable analysis.

RESULTS

Baseline Characteristics

There were 94 patients, comprised of 30

(31.9%) female and 64 (68.1%) male

patients, at a mean age of 48.8 years old

(range =14–89 y). The mean LVEF was

19.4%. Concerning the NYHA functional

class, 2 (2.1%) patients were in class II, 71

(75.5%) in class III, and 21(22.3%) in class

IV. Twenty-nine (30.9%) patients had DCM.

All the patients were on standard

recommended medical treatment for HF,

including angiotensin-converting enzyme

(ACE) inhibitors/angiotensin receptor blocker

(ARB), beta-blockers, spironolactone,

diuretics, and digoxin. The mean number of

admission days was 13.3 days (3–42 d).

Thirty-eight (40.4%) patients had re-admission.

Serum prolactin changes between the acute

phase of heart failure and after guideline-

directed medical therapy and before

discharge and its associations with the

NYHA function class and other prognostic

factors

The mean serum PRL level in the acute phase

was 31.3 ng/mL, which was significantly

higher than the normal reference values

(4.04–15 ng/mL) (P < 0.001). The mean

serum PRL level before discharge was 34.84

ng/mL, which was significantly higher than

the normal reference values and similar to the

values in the acute phase. The mean PRL

level in the patients with DCM was 33.61

ng/mL in the acute phase and 43.15 ng/mL

after the GDMT of HF. The mean PRL level

in the non-DCM patients was 33.42 ng/mL in

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the acute phase and 29.92 ng/mL before

discharge. The mean PRL level in the patients

with re-admission was higher (27.7 ng/mL in

the acute phase and 29.7 ng/mL before

discharge in the patients with no re-admission

and 37.4 ng/mL in the acute phase and 42.5

ng/mL before discharge in the patients with

re-admission). The mean PRL level in the

female patients, pre and post treatment, was

higher than that in the male patients. Vis-à-

vis the TSH level, none of the patients had

hypothyroidism. As an important prognostic

factor in these patients, the associations

between the NYHA function class, serum

PRL pre and post treatment, and the other

prognostic factors were assessed specifically.

The mean PRL level in the patients with

DCM after treatment and before discharge

was higher than that in the non-DCM patients

(43.15 ng/mL vs 29.92 ng/mL), but there was

no significant correlation. The mean PRL

level in the patients with re-admission was

higher, but the difference did not constitute

statistical significance. The relationships

between the serum PRL level and the other

prognostic factors were also investigated. No

significant correlations were seen between

PRL and age (r = 0.05 ; P = 0.64), erythrocyte

sedimentation rate (r = 0.05; P = 0.59), hs-

CRP (r = -0.06 ; P = 0.67), serum sodium (r =

-0.04 ; P = 0.69), serum uric acid (r = 0.10 ; P

= 0.39), serum creatinine (r = 0.04; P = 0.66),

NT-proBNP (r = 0.07; P = 0.51), and duration

of hospitalization (r = -0.014 ; P = 0.89).

Findings in the patients’ follow-up

All the patients were followed up for 6

months for events such as mortality due to

HF, hospitalization for acute HF, and

transplantation. During this follow-up period,

20 (21.2%) patients died (all of them with

LVEF < 20% and NYHA class IV).

Additionally, 7 (7.4%) patients underwent

transplantation and 38 (40.4%) were

hospitalized at least once with a diagnosis of

acute HF. The patients with events had higher

NT-proBNP, hs-CRP, and TSH levels and

lower LVEF and 6MWT. Nevertheless,

except for NT-proBNP, none of the

differences was statistically significant.

Despite the higher mean level of PRL in the

patients with re-admission and in those with

DCM, this correlation was not significant.

DISCUSSION

In the present study, we found a higher-than-

normal serum PRL concentration among our

94 patients. There are several reports on the

measurement of the serum PRL level in

patients with HF. Opalinska et al 3 measured

the levels of several hormones, including

PRL, in 27 male patients suffering from HF

with an LVEF < 35% and found

hyperprolactinemia. Limas et al

4 reported

that hyperprolactinemia was present in 25%

of their patients with HF. In 2 recent studies,

Landberg et al 5 and Parissis et al

6 showed

elevated levels of serum PRL in different

groups of patients with HF.

The aim of the current study was to assess the

PRL level in patients admitted with acute HF

and post GDMT with a view to assessing

whether or not PRL has an acute-phase

reactant role. We presumed that PRL might

be an acute-phase reactant and elevated levels

of PRL in the acute phase might decrease

following the GDMT and stabilization of

patients. In this study, the mean level of PRL

was significantly different from its normal

value, especially in the patients with DCM.

In 57% of our patients, the mean level of PRL

increased after treatment. The mean level

remained unchanged in 3.5% of the patients

and decreased in the remaining 39.2%. In

light of this finding, it can be posited that

PRL may play a role more than that of an

acute-phase reactant alone. Be that as it may,

larger studies are required to shed sufficient

light on the role of PRL in patients with HF.

Research into the treatment of patients

suffering from HF with high levels of PRL

following the GDMT of HF with

bromocriptine may have consequences like

those in PPCMP.

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One of the strengths of this study is its

utilization of a new design to clarify the role

of PRL in patients with HF.

CONCLUSIONS

PRL, as a multifunctional hormone, plays an

important role in immune-regulation,

osmoregulation, metabolism, and

angiogenesis 3-7

and there is substantial

evidence in favor of its involvement in the

pathogenesis of PPCMP. 10

However, given

the results of the current and other studies

regarding the role of PRL in patients with HF,

this role cannot simply be considered as a

prognostic factor in HF and further

investigations are needed to shed more light

on the role of PRL in the pathophysiology of

HF.

ACKNOWLEDGEMENTS

This research project was financially

supported by Rajaie Cardiovascular, Medical,

and Research Center, Iran University of

Medical Sciences, Tehran, I.R. Iran.

REFERENCES

1. McMurray JJ, Adamopoulos S, Anker SD,

Auricchio A, Bohm M, Dickstein K, et al.

ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure

2012: The Task Force for the Diagnosis and

Treatment of Acute and Chronic Heart Failure

2012 of the European Society of Cardiology.

Developed in collaboration with the Heart

Failure Association (HFA) of the ESC. Eur

Heart J. 2012;33(14):1787–847.

2. Sacca L. Heart failure as a multiple hormonal

deficiency syndrome. Circ Heart Fail. 2009;

2(2): 151–6.

3. Hilfiker-Kleiner D, Kaminski K, Podewski E,

Bonda T, Schaefer A, Sliwa K, Forster O,

Quint A, Landmesser U, Doerries C,

Luchtefeld M, Poli V, Schneider MD,

Balligand JL, Desjardins F, Ansari A, Struman

I, Nguyen NQ, Zschemisch NH, Klein G,

Heusch G, Schulz R, Hilfiker A, Drexler H. A

cathepsin D-cleaved 16 kDa form of prolactin

mediates postpartum cardiomyopathy. Cell.

2007; 128: 589 – 600.

4. Anker SD, Chua TP, Ponikowski P,

Harrington D, Swan JW, Kox WJ, et al.

Hormonal changes and catabolic/anabolic

imbalance in chronic heart failure and their

importance for cardiac cachexia. Circulation.

1997; 96(2): 526–34.

5. Sacca L. Heart Failure as a Multiple

Hormonal Deficiency Syndrome. Circ Heart

Fail. 2009; 2(2): 151–6.

6. Kontoleon PE, Anastasiou-Nana MI,

Papapetrou PD, Alexopoulos G, Ktenas V,

Rapti AC, et al. Hormonal profile in patients

with congestive heart failure. Int J Cardiol.

2003; 87(2-3):179–83.

7. Lamblin N, Mouquet F, Hennache B, Dagorn

J, Susen S, Bauters C, et al. High-sensitivity

C-reactive protein: potential adjunct for risk

stratification in patients with stable congestive

heart failure. Eur Heart J. 2005; 26(21): 2245–

50.

8. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen

EL, Pugsley SO, Taylor DW, et al. The 6-

minute walk: a new measure of exercise

capacity in patients with chronic heart failure.

Can Med Assoc J. 1985; 132(8): 919–23

9. Fruhwald FM, Fahrleitner A, Watzinger N,

Dobnig H, Schumacher Naderi N et al. Res

Cardiovasc Med. 2014; 3(3): e19321 5 M,

Maier R, et al. N-terminal proatrial natriuretic

peptide correlates with systolic dysfunction

and left ventricular filling pattern in patients

with idiopathic dilated cardiomyopathy. Heart.

1999; 82(5): 630–3

10. Ridker PM. High-sensitivity C-reactive

protein: potential adjunct for global risk

assessment in the primary prevention of

cardiovascular disease. Circulation. 2001;

103(13): 1813–8.

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Coronary Vessel Diameter During and After Primary PCI in Patients With Acute Ml Shakerian F, et al

25

Original Article Coronary Vessel Diameter During and After Primary PCI in Patients With Acute Ml Shakerian F, et al

Comparison of the Coronary Vessel Diameter During and After

Primary Percutaneous Intervention in Patients with Acute

Myocardial Infarction

Farshad Shakerian 1, MD;

Roya Rezai*

2, MD; Fatemeh Shiokhi

2, MD;

Ata Firouzi 1, MD; Hamidreza Sanati

1, MD; Ali Zahedmehr

1, MD;

Reza Kiani 1, MD; Omid Shafe

1, MD; Samaneh Ahmadi

2, MD

ABSTRACT

Background: An increase in the plasma levels of catecholamines and other neurohormones after

acute myocardial infarction (AMI) leads to coronary vasoconstriction and may cause the

undersizing of stents during primary percutaneous coronary intervention (PCI) in ST-

segment elevation myocardial infarction (STEMI). We aimed to compare the reference

vessel diameter of the infarct-related artery during and after primary PCI in patients with

AMI.

Methods: This prospective interventional study was performed on 43 consecutive patients with

STEMI (TIMI flow grade III), who were candidated for primary PCI. The main proximal

diameter of the coronary artery (reference vessel diameter) was assessed at baseline and also

3 days to 3 months after 2nd angiography. The study end point was to compare the reference

vessel diameter within and after primary PCI.

Results: Comparison between the mean diameter of the involved coronaries after PCI and the mean

diameter during the procedure showed a significant increase in the real size of the right

coronary artery (RCA) and a slight decrease in the size of the left circumflex artery (LCx).

However, the mean sizes of the left anterior descending coronary artery remained

insignificant. The decrease in the LCx diameter and inversely the increase in the RCA

diameter remained significant in the study population even after adjusting cardiovascular

risk factors as potential confounders.

Conclusions: The changes in the diameter of the reference coronary arteries, namely an increase in

the RCA diameter and a decrease in the LCx diameter, are expected following primary PCI

in patients with STEMI. (Iranian Heart Journal 2017; 18(1):25-29)

Keywords: Primary percutaneous coronary intervention, Acute myocardial infarction, Intervention

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: Roya Rezai, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I.R.

Iran.


Received: 17 October, 2016 Accepted: January 20, 2017


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he sympathetic nervous system and

myocardial ischemia link together and,

thus, the activation of the sympathetic

and adrenal systems leads to increased levels

of circulating catecholamines, epinephrine,

and norepinephrine and accelerates the

development of ischemic heart disease and

acute myocardial infarction (AMI). 1, 2

The

increase in catecholamines occurs early in

AMI and majorly affects the course of AMI.

There is a close association between

catecholamines and the infarct size and the

progression of myocardial cell damage. 3

Various mechanisms may account for the

local accumulation of catecholamines in the

extracellular space of the ischemic

myocardium. 4 In early MI, plasma

noradrenaline and adrenaline concentrations

are enhanced, reflecting the increased activity

of the whole sympathetic nervous system. 5 In

other words, even mildly increased levels of

plasma catecholamines directly induce a

major deterioration of myocardial function

during the ischemic process. 6 More

interestingly, the plasma levels of

catecholamines and other vasopressors are

elevated during AMI and coronary

vasoconstriction is frequent, which may lead

to the undersizing of stents during primary

percutaneous coronary intervention (PCI) in

ST-segment elevation myocardial infarction

(STEMI). 7, 8

This size underestimation may

even give rise to higher rates of stent

thrombosis and, thus, poorer prognosis of

STEMI.

We aimed to compare the reference vessel

diameter (RVD) of the infarct-related artery

during and after primary PCI in patients with

AMI.

METHODS

This prospective interventional study was

performed on 43 consecutive patients with

STEMI, who were candidated for primary

PCI. All the eligible patients had more than 1

involved coronary vessel and needed staged

PCI. In all the subjects, the involved vessel

was opened (TIMI flow grade III) and PCI

was conducted on the non-culprit vessel

within further angiography. Initially, the main

proximal diameter of the coronary artery

(RVD)—after the separation of the vessel at a

distance of 3 mm from the ostium—was

assessed via quantitative coronary

angiography at baseline and also 3 days to 3

months after 2nd angiography. The study end

point was to compare the RVD within and

after primary PCI.

The results are presented as mean ± standard

deviation (SD) for the quantitative variables

and are summarized by frequencies

(percentages) for the categorical variables.

The continuous variables were compared

using the t-test or the Mann–Whitney test

whenever the data did not appear to have a

normal distribution or when the assumption of

equal variances was violated across the study

groups. The categorical variables were, on the

other hand, compared using the χ2 test. The

changes in the parameters after the

intervention were compared to the values

before the intervention using the paired t-test.

For the statistical analyses, the statistical

software SPSS, version 16.0, for Windows

(SPSS Inc, Chicago, IL) was employed. A P

value ≤ 0.05 was considered statistically

significant.

RESULTS

The average age of the patients was

59.77±10.52 years, and 74% of them were

male. Regarding the cardiovascular risk

profile, 44.2% of the patients were diabetics,

34.9% were hypertensive, 39.5% were

hyperlipidemic, and 48.8% were smokers.

Family history of coronary artery disease was

revealed in 18.6%, and 16.3% were found to

have ischemic heart disease. As is shown in

Table 1, a comparison of the mean diameter

of the involved coronaries after PCI compared

to that during the procedure showed a

significant increase in the real size of the right

T

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coronary artery (RCA) as well as a slight

decrease in the size of the left circumflex

artery (LCx). Nevertheless, the mean sizes of

the left anterior descending coronary artery

remained insignificant. A comparison of the

mean arterial sizes after primary PCI between

the men and women demonstrated only a

significant increase in the RCA size in the

men (P = 0.049). Also, the assessment of the

change in the mean diameters of the involved

arteries in the different age subgroups showed

a significant decrease in the LCX size only in

the patients aged 60 to 75 years (P = 0.055).

No significant difference was found in the

mean diameters of all the coronaries after PCI

in both diabetics and nondiabetics. Moreover,

a significant decrease in the mean LCx

diameter (P = 0.039) as well as an increase in

the mean RCA diameter (P = 0.021) after PCI

was detected only in the normotensive

patients. Additionally, a significant increase

in the mean RCA diameter was observed only

in the hyperlipidemic subjects (P = 0.022).

There was also a significant decrease in the

mean LCx diameter following PCI in the

smokers (P = 0.054), and not in the

nonsmokers. Positive family history of

coronary artery disease did not affect the

change in the mean size of the coronary

vessels after PCI. In total, the difference in

the mean diameters of all the coronary vessels

remained significant between the men and the

women, between the different age subgroups,

and between the subgroups with and without

each of the cardiovascular risk factors. In the

multivariable linear regression model, only

hypertension was identified to predict the

change in the LCx real size after primary PCI.

Also, a similar regression model showed that

none of the baseline variables could predict

the change in the mean diameters of the

coronary arteries following PCI (Table 2 and

Table 3).

Table 1. Change in the mean coronary artery diameters at secondary compared

with primary angiography after primary percutaneous coronary intervention

P Secondary Primary N=43

0.467 3.52 ± 0.77 3.60 ± 0.81 Mean LAD real size

0.057 3.14 ± 0.64 3.31 ± 0.89 Mean LCx real size

0.033 3.95 ± 0.99 3.69 ± 0.87 Mean RCA real size

0.688 3.64 ± 0.87 3.57 ± 0.96 Mean lesion real size

LAD, Left anterior descending coronary artery; LCx, Left circumflex coronary artery; RCA, Right coronary artery

Table 2. Multivariable linear regression modeling to assess changes in the LCx diameter with the presence of

potential confounders

Model

Unstandardized Coefficients

Standardized Coefficients t P

B Std. Error Beta

1 (Constant) 1.685 .427 3.944 .000

Primary LCx real size .490 .080 .682 6.116 .000

Gender -.218 .197 -.150 -1.103 .278

Hypertension .436 .194 .328 2.245 .031

Hyperlipidemia .100 .152 .077 .656 .516

Cigarette smoking -.156 .159 -.123 -.982 .333

Family history .035 .177 .022 .198 .844

Age level .012 .098 .014 .127 .900

Ischemic heart disease -.336 .236 -.196 -1.425 .163

a. Dependent variable: secondly LCX real size

LCx, Left circumflex coronary artery

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Table 3. Multivariable linear regression modeling to assess changes in the RCA diameter with the presence of

potential confounders

Model

Unstandardized Coefficients

Standardized Coefficients t P

B Std. Error Beta

1 (Constant) 1.202 .843 1.426 .163

Primary RCA real size .803 .153 .701 5.253 .000

Gender -.032 .357 -.014 -.089 .930

HTN -.142 .354 -.069 -.401 .691

HLP .268 .271 .133 .987 .330

CS -.012 .286 -.006 -.043 .966

FH -.118 .323 -.047 -.365 .717

Age level -.065 .180 -.048 -.365 .718

IHD -.274 .439 -.103 -.625 .536

a. Dependent variable: secondary RCA real size

RCA, Right coronary artery; HTN, Hypertension; HLP, Hyperlipoproteinemia; CS, Carotid stenosis; FH, Family history; HIS, Ischemic heart disease

DISCUSSION

Our study succeeded in finding an

interestingly paradoxical change in diameters

at the secondary angiographic assessment of

stented coronary arteries when compared to

primary assessments. There was a significant

reduction in the size of the LCx, while there

was an increase in the size of the RCA after

stenting in our patients with STEMI. More

interestingly, the size of the left anterior

descending artery or even the size of the

lesions remained unchanged. Some similar

changes were also revealed in different

subgroups of cardiovascular disorders,

whereby the change in the RCA diameter was

only observed in the men and also in the

hyperlipidemic ones (not in the women).

Additionally, the change in the LCx was

observed in those aged between 60 and 75

years and in those with a history of smoking.

Further, the change in the LCx size was

observed in the normotensive patients and in

those without family history of coronary

artery disease. To determine the predicting or

confounding role of the baseline risk profile

in the changes in the arterial diameters, we

employed the multivariable logistic regression

models and managed to show that the role of

these baseline factors was all limited to their

confounding effects. In other words, a

reduction in the LCx diameter and inversely

an increase in the RCA diameter remained

significant in the study population even after

adjusting cardiovascular risk factors as the

potential confounders. Moreover, it seems

that the conflicting changes found in the LCx

and RCA may have been related to the special

anatomical patterns of each coronary artery

and, thus, different effects of catecholamine

and other hormones on their specific receptors

on the arterial walls. In total, as was

previously described, in the early phases of

AMI, the activation of the sympathetic

nervous system can lead to a rise in

noradrenaline and adrenaline concentrations,

which act as vasopressors, and result in

coronary vasoconstriction. 5, 6

This pathway

may cause underestimation of the considered

stents and lead to deterioration of the stenting

outcome. Accordingly, the assessment and

prediction of the change in the diameters of

the coronary vessels, especially in the LCx

and RCA, should be considered to improve

the procedural outcome.

Our literature review found a limited number

of similar studies on the change in non-culprit

vessels within secondary angiography. In a

similar study by Sahin et al, 7 coronary

angiography on 58 patients with STEMI after

PCI showed significant elevations in the

coronary artery diameter with lowering the

area of the lesion. Elsewhere, Cristea et al 8

evaluated 2974 patients with 3589 lesions

undergoing 2233 stentings and reported an

initially higher mean coronary artery

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diameter, which was alternatively reduced at

1-year follow-up. The latter study, thus,

shows that the significant change in the

arterial diameter after PCI may be time-

independent and reversing the diameter can be

also predicted in a long-term period after

stenting.

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doi: 10.1016/j.ahj.2011.04.016. Epub 2011

Jun 12.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Cristea%20E%5BAuthor%5D&cauthor=true&cauthor_uid=21742105

http://www.ncbi.nlm.nih.gov/pubmed/?term=Stone%20GW%5BAuthor%5D&cauthor=true&cauthor_uid=21742105

http://www.ncbi.nlm.nih.gov/pubmed/?term=Mehran%20R%5BAuthor%5D&cauthor=true&cauthor_uid=21742105

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kirtane%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=21742105

http://www.ncbi.nlm.nih.gov/pubmed/?term=Brener%20SJ%5BAuthor%5D&cauthor=true&cauthor_uid=21742105

http://www.ncbi.nlm.nih.gov/pubmed/21742105

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CMR in Predicting PAP in MS Patients After Surgical or Interventional Treatment Sanati H, et al

30

Original Article CMR in Predicting PAP in MS Patients After Surgical or Interventional Treatment Pouraliakbar H.R, et al

Cardiovascular Magnetic Resonance in Predicting the Reduction in

Pulmonary Artery Pressure in Patients With Mitral Stenosis After

Surgical or Interventional Treatment

Hamidreza Sanati 1, MD; Reza Rezaei Tabrizi

2, MD;

Hamid Reza Pouraliakbar 2*

, MD; Ali Zahedmehr 1, MD; Ata Firouzi

1, MD;

Farshad Shakerian 1, MD; Reza Kiani

1, MD; Nasim Naderi

2, MD

ABSTRACT

Background: Pulmonary hypertension (PH) is a common consequence of mitral stenosis (MS).

After treatment, PH reverses depending on the chronicity and severity of MS. The

characteristic changes in the pulmonary artery (PA) secondary to an elevated pulmonary

artery pressure (PAP) can be evaluated via cardiovascular magnetic resonance imaging

(CMR). In this study, we aimed to evaluate if there was any correlation between PAP and

hemodynamic findings measured by CMR and whether these findings could be useful in

predicting the PAP response after MS relief.

Methods: Thirty-three patients with a diagnosis of severe MS, who were candidated for

percutaneously transvenous mitral commissurotomy (PTMC) or mitral valve replacement

(MVR), were included. CMR was performed in all of them before the procedure and PA

distensibility, PA peak velocity, PA forward volume, and PA forward flow were measured.

Transthoracic echocardiography was performed at baseline, immediately after the

procedure, and 3 months after MS relief for the assessment systolic PAP.

Results: Thirty-three patients with a diagnosis of MS+PH (15 PTMC and 18 MVR) were enrolled

in this study. The mean PAP at baseline catheterization ranged from 25 to 70 mm Hg. There

was a significant drop in systolic PAP immediately after the procedure and 3 months after

MS relief. There was no relationship between the PA distensibility index and systolic PAP

changes after MS relief. PA peak velocity was significantly higher in the patients with >

50% drops in their systolic PAP 3 months after the treatment. The multivariable analysis

showed that none of the CMR findings was an independent predictor of a more systolic PAP

decline.

Conclusions: Although we found no significant relationship between CMR findings and systolic

PAP changes after MS treatment, the result of this study can be used for further

investigations in this regard. (Iranian Heart Journal 2017; 18(1):30-36)

Keywords : Pulmonary artery pressure, Cardiovascular magnetic resonance imaging, Mitral stenosis

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: Hamid Reza Pouraliakbar, MD; Rajaie Cardiovascular , Medical , and Research Center, Iran University of Medical

Sciences, Tehran, I.R. Iran.


Received: October 17, 2016 Accepted: January 23, 2017

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&sqi=2&ved=0CBwQFjAAahUKEwiu-fLToYXIAhVEjdsKHazvDbc&url=http%253A%252F%252Fwww.ncbi.nlm.nih.gov%252Fpubmed%252F22368914&usg=AFQjCNH9rrX2tco7frsQr_4dm1RUjZDHQg&sig2=nuPixZYXerlzZ5EpyqY5-Q


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31

ulmonary hypertension (PH) is a

common consequence of left-heart

diseases, including mitral stenosis

(MS). 1-3

Pulmonary artery pressure (PAP)

rises chronically in these patients as a result

of chronic pathological changes in pulmonary

arteries and veins secondary to an increase in

left ventricular filling pressures. After

treatment, PH reverses depending on the

chronicity and severity of MS and the

underlying pathophysiological remodeling. 2,

3 Generally, in MS, a rapid decline in PAP is

observed after relieving the stenosis.

However, PAP remains high or decline more

slowly in some patients. 2, 3

The prediction of

the PAP response to the treatment is very

difficult. Consequently, an investigation of

the predictive factors is of great importance.

Cardiovascular magnetic resonance imaging

(CMR) has been used in the evaluation of PH

for the past 25 years. 4-7

The characteristic

changes of the right heart and the pulmonary

artery (PA) secondary to an elevated PAP can

be evaluated via CMR examination, 4-12

In this study, we aimed to evaluate whether

there was any correlation between PAP and

hemodynamic findings measured by CMR

and whether these findings could be useful in

predicting the PAP response after MS relief.

METHODS

In this case series, a total of 33 patients with

severe rheumatismal MS who had PH (mean

PAP ≥ 25 mm Hg in right-heart

catheterization) and were candidated for

percutaneous transvenous mitral

commissurotomy (PTMC) or mitral valve

replacement (MVR) in Rajaie Cardiovascular,

Medical, and Research Center were included.

The diagnosis of severe MS (mitral valve area

[MVA] < 1.5 cm2) was made in accordance

with the European guideline for the

management of valvular heart disease. 1 The

presence of PH was confirmed in the

catheterization laboratory using the European

guideline for the diagnosis and management

of PH. 2

The exclusion criteria were comprised of the

presence of other valvular heart diseases with

more than moderate severity needing

intervention, mitral regurgitation, significant

left ventricular (LV) systolic dysfunction (left

ventricular ejection fraction [LVEF] ≤ 40%),

and inability to attend the CMR field

(claustrophobia).

Echocardiographic examination

Comprehensive transthoracic echocardio-

graphy was performed by an

echocardiography specialist using a Vivid 7

ultrasound system (GE Medical System,

Horton, Norway) and a 1.7/3.4 MHz

transducer. Images were acquired with the

subjects at rest, lying in the left lateral supine

position at the end of expiration. 2D ECG was

superimposed on the images, and end-diastole

was considered at the peak R-wave of the

ECG. LV global systolic function was

evaluated using a modified biplane Simpson

method for calculating LVEF. In all the

patients, the MVA was assessed using the 2D

planimetry method in the parasternal short-

axis view at valve tips. PAP was evaluated

considering the guidelines on the assessment

of the right heart before the procedure, the 1st

time after the procedure during index

hospitalization and subsequently 3 months

after discharge.

Cardiovascular magnetic resonance

examination

CMR with 1.5-T clinical magnet (Magnetom

Avento; Siemens Medical Solutions,

Erlangen, Germany) with a gadolinium-based

contrast agent (Magnevist ) was performed,

and the following data were obtained from a

thorough CMR examination: PA diameter in

systole and diastole, distensibility index (the

difference between the maximum and

minimum PA diameter divided by the

maximum diameter), PA peak velocity, PA

forward volume, PA forward flow.

CMR study was performed with the patients

in the supine position by using a phased-array

P



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surface coil as a receiver and retrospective

ECG gating. Images were obtained during

end-expiratory breath holds preceded by brief

hyperventilation. After obtaining standard

localizer views, 2 double-oblique views

oriented along the main axis of the pulmonary

trunk and the ascending aorta were acquired

with a standard steady-state free precession

cine MR sequence. The 1st one was in a

double-oblique section perpendicular to the

direction of the ascending aorta at the level of

the pulmonary bifurcation, and the 2nd was in

a double-oblique section perpendicular to the

main PA, 10 mm above the pulmonary valves.

Only 1 set of velocity measurements was

acquired for each patient, perpendicular to the

main PA.

Both cine loops were used as the reference to

prescribe a plane truly perpendicular to the

main PA for the acquisition of phase-contrast

MR images and to ensure that the imaging

plane remained between the pulmonary valve

and the PA bifurcation throughout the whole

cardiac cycle.

The imaging plane was selected on an oblique

sagittal localizing image that showed the

ascending aorta. We preferred an imaging

plane at the level of the pulmonary bifurcation

since it was easy to reproduce. This imaging

plane also had a sufficient distance from the

aortic valve so that the effect of mild valvular

disease did not disturb the flow

measurements.

Phase-contrast MR images were acquired

with a segmented fast gradient-echo MR

sequence , with velocity encoding

perpendicular to the imaging plane and a

predefined upper velocity limit of 100 cm/sec.

If aliasing was noted, the velocity was

progressively raised in 50-cm/sec steps until

the aliasing disappeared. Imaging parameters

comprised the following: 7.5/3.1; flip angle,

15°; section thickness, 6 mm; field of view,

320–380 × 240–300 mm; matrix, 256 × 128

(typical in-plane resolution, 2.7 × 1.4 mm);

number of signals acquired, 1; number of

segments, 5 to 7; temporal resolution, 75–105

msec; number of reconstructed cardiac

phases, 20; and bandwidth, 260 Hz/pixel. The

typical breath-hold time ranged from 15 to 25

seconds. The patients were encouraged to

hold their breath during the whole acquisition.

Supplemental oxygen was administered as

clinically indicated or if the patients

experienced difficulties completing the period

of apnea. If obvious breathing artifacts were

noted, the acquisition was repeated.

The study was approved by institutional

research and ethics committee, and informed

consent was obtained from all the study

participants.


All the analyses were conducted using SPSS

software, version 22 (SPSS Inc, Chicago, IL,

USA). All the data initially were analyzed

using the Kolmogorov–Smirnov test to assess

for normality. The categorical variables are

presented as numbers (percentages) and

analyzed using the χ2 test. The normally-

distributed quantitative variables are

presented as means ± standard deviations

(SDs) and those with non-Gaussian

distributions are presented as medians

(interquartile ranges [IQRs]). For the

analysis of the quantitative variables, the

Student t-test was drawn upon. The

relationships were assessed using the

Spearman rank correlation coefficient (ρ) or

the Pearson correlation test as appropriate.

Binary logistic regression analysis was

applied to assess the independent CMR

factors associated with a higher drop in

systolic PAP (> 50% decline in systolic PAP

or systolic PAP ≤ 35 mm Hg immediately

after the procedure or 3 months after the

procedure). All the P values were 2-tailed,

and a P value < 0.05 was considered

statistically significant.

RESULTS

Thirty-three patients with a diagnosis of

MS+PH (15 patients scheduled for PTMC and

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18 for MVR) were enrolled in this study.

About 70 % of the patients were female and

the mean (SD) of age was 51.3 (12) years

(between 32 and 74 y).The most common

chief complaint was dyspnea on exertion,

which was obvious in all the patients.

The median (IQR) of the MVA was 0.82

(0.5–1.3) cm2, and the mean (SD) of systolic

PAP was 62 (19) mm Hg in baseline

echocardiography. The mean PAP at baseline

catheterization ranged from 25 to 70 mm Hg

in our study population (mean [SD] = 42

[12.1]).

Table 1 shows the demographic, echocardio-

graphic, and hemodynamic findings of the study

population. There was a significant drop in

systolic PAP immediately after the procedure and

3 months after MS relief compared to before the

treatment in our study population.

The mean (SD) of systolic PAP was 62 (19)

mm Hg, which dropped to 44.7 (13.7) and

36.7 (9.7) mm Hg immediately after the

procedure and 3 months afterward,

respectively (P<0.001 for both

measurements).

Table 1. Demographic, clinical, and echocardiographic findings of the study population (N=33)

Characteristics

Mitral Stenosis Treatment Group (N=33)

P MVR (n=18)

PTMC (n=15)

Age (y) mean (SD) 48.6(11.5) 53.5(12.2) 0.2

Gender, F/M, count (%) 11(47.8)/4(40) 12(52.2)/6(60%) 0.5

NYHA class, count (%)

I-II,II 7(46.6) 8(44.4)

0.1 II-III,III 6(40) 7(38.9)

IV 2(13.3) 3(16.7)

Orthopnea, count (%) 4(27) 8(44.4) 0.04

Palpitation, count (%) 6(40) 7(38.9) 0.2

Chest pain, count (%) 2(13.3) 3(16.7) 0.6

Concomitant CAD, count (%) 1(6.7) 1(5.6) 0.3

LVEF, %, mean (SD) 49.6(7.2) 47.7(7.1) 0.3

MVA,cm2, median (IQR) 0.7(0.6-1.1) 0.9(0.7-1) 0.5

Baseline PASP 65.7(25) 59(12) 0.3

PASP after the procedure 46(13) 43.6(13.8) 0.6

PASP 3 months after the procedure

38.3(11.6) 35.3(7.8) 0.4

NYHA, New York Heart Association; LVEF, Left ventricular ejection fraction; MVA, Mitral valve area; PASP, Pulmonary artery systolic pressure

Cardiac magnetic resonance findings

Table 2 shows the CMR findings in our study

population. There was no relationship

between the PA distensibility index and

systolic PAP at baseline, immediately after

the procedure, or 3 months after the treatment.

There was also no difference between the

patients who had a greater drop in their

systolic PAP (systolic PAP < 35 mm Hg or >

50% decrease in systolic PAP) and those who

did not regarding the PA distensibility (P =

0.3).

The PA peak velocity was significantly higher

in the patients who had > 50% drops in their

systolic PAP 3 months after the treatment

compared to the baseline (mean [SD] PA peak

velocity [cm/sec] = 76.2 [20] vs 60 [16.7]) ( P

= 0.04). The PA forward volume and the PA forward flow

showed no association with baseline systolic PAP

or systolic PAP after the treatment. However, in

the subgroup analysis, the PA forward flow

showed a significant negative correlation with

systolic PAP 3 months after the procedure in the

PTMC group (P = -0.6 and P = 0.01).

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The multivariable analysis was performed using

binary logistic regression with the low likelihood

backward elimination method to assess whether

any CMR findings might predict > 50% drops in

systolic PAP 3 months after MS relief

independently. This analysis showed that none of

the above-mentioned CMR findings was an

independent predictor of a more systolic PAP

decline. The same result was observed when we

considered a systolic PAP < 35 mm Hg 3 months

after MS relief as the end point in the

multivariable analysis.

Table 2. Cardiac magnetic resonance findings in the study population (N=33)

Characteristics

Mitral Stenosis Treatment Group (N=33) P

PTMC N=15

MVR N=18

Distensibility, %,mean (SD) 21(8) 21(9) 0.9

PA peak velocity, cm/sec, mean (SD) 65.7(21.5) 59.8(17.4) 0.3

PA flow per minute, ,mean (SD) 6(1.7) 5.8(1.3) 0.7

PA forward Volume mean (SD) 80.6(33) 75.5(19.2) 0.5

PA, Pulmonary artery

DISCUSSION

In the present study, we could not find any

relationship between PA hemodynamic

measures in CMR and systolic PAP in our

severe MS patients with PH in the

multivariate analysis and none of the CMR

hemodynamic measures was independently

correlated with systolic PAP. It is, therefore,

not useful for predicting PH reversal after MS

relief.

Recently, many investigators have focused on

CMR findings in PH in order to better

manage approaches and follow-ups. 5, 7, 8, 10-

19 Several studies in idiopathic pulmonary

arterial hypertension (IPAH) have shown a

significant relationship between PA peak

velocity, distensibility, and PA forward flow

and hemodynamic findings including

vasoreactivity. 10, 11, 13, 14, 16

We aimed to

assess such correlations in patients with MS

and PH as another category of PH. However,

despite a good correlation between PAP and

PA distensibility as well as PA velocity in

CMR among the patients with IPAH in some

studies, systolic PAP at baseline as well as

post procedure was not associated with these

variables in our study population.

The only positive finding of the present study

was a higher PA peak velocity in the patients

who had > 50% drops in their systolic PAP 3

months after MS relief, which showed a

higher reversibility tendency in this group of

patients. Laffon et al 15, 16

studied IPAH

patients and showed that those with a higher

PA velocity were more probable to be

vasoreactive to pulmonary vasodilators in the

vasoreactive challenge test. A similar

mechanism can be considered for our study

population. However, the multivariable study

demonstrated that none of these factors,

including PA peak velocity, was

independently correlated with a higher drop in

systolic PAP. The different pathophysiologic

mechanism for PH in MS setting (post

capillary PH) might be responsible for this

finding.

On the other hand, our sample size was small

and we considered systolic PAP measured by

echocardiography. Our results would have

been augmented had we been able to consider

catheterization data, including mean PAP,

pulmonary vascular resistance, and trans-

pulmonary gradient.

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CONCLUSIONS

Considering the limitation of this study, we

would recommend that future studies

investigate the association between

catheterization data as gold standard and

CMR findings in different categories of PH.

These studies may shed some light on the

pathophysiologic mechanisms in PH and

enhance the management and follow-up of

this group of patients.

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Scheidler J, Dietrich O, Kuehn B, et al.

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Rubenfeld G, Jasinowodolinski D, Carvalho

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Outcome of Carotid Stenting in Patients Undergoing Angioplasty Abdi S, et al

37

Original Article Outcome of Carotid Stenting in Patients Undergoing Angioplasty Abdi S, et al

Outcome of Carotid Stenting in Patients Undergoing Angioplasty

Seifolah Abdi 2, MD; Faramarz Amiri

1, MD; Omid Shafe*

2, MD;

Reza Ebrahmi Rad 3, MD; Hamid Fakhreddin

1, MD; Alireza Jebeli

1, MD;

Seyed Abdullah Sayadmanesh 1, MD; Moslem Shadmani

1, MD;

Ebrahim Ghobadi 1, MD

ABSTRACT

Background: Carotid artery stenosis accounts for 10% of all ischemic strokes. Carotid

endarterectomy (CEA) and carotid artery stenting (CAS) are currently the treatment for

stroke prevention.

Methods: We sought to compare the efficacy and safety of each treatment in patients with carotid

artery stenosis. After treatment, the patients were evaluated regarding their outcomes during

the 1st and 6th postprocedural months.

Result: Sixty-nine patients (45 male [65.2%] and 24 female [24.8%]) at a mean age of 63.85 ±

14.17 years were enrolled. In 12 (17.4%) patients, both left and right carotid arteries were

stenotic. Neither CEA nor CAS had in-hospital and procedural complications. However, in

longer-term follow-up, transient ischemic attack occurred in 2 (2.9%) patients in the CEA

group, while significant in-stent restenosis occurred in 2 (2.9%) patients after CAS.

Multivariate analysis showed no association between smoking, coronary artery disease,

dyslipidemia, hypertension, diabetes mellitus, and age and stent stenosis (P = 0.9, P = 0.9,

P = 0.5, P = 0.6, P = 0.8, and P = 0.1, correspondingly).

Conclusions: Both CEA and CAS are approved therapeutic strategies for the treatment of carotid

artery stenosis. Low complications and good results can be expected if case selection is done

according to the current guidelines. (Iranian Heart Journal 2017; 18(1):37-43)

Keywords: Carotid stenosis, Carotid artery stenting, Carotid endarterectomy

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. 3 Azad Islamic University Complex, Tonekabon Mazandaran, I.R. Iran.

*Corresponding Author: Omid Shafe, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran,

I.R. Iran.


Received: October 30, 2016 Accepted: February 4, 2017

or the treatment of extracranial carotid

artery disease in patients at high risk

for adverse events, in 2004, the United

States’ Food and Drug Administration (FDA)

approved the 1st endovascular device system,

carotid endarterectomy (CEA), for practice in

the country. Meanwhile, carotid artery

stenting (CAS) has been performed with

increasing numbers in different hospital

settings. After the 1st adoption phase in CAS,

F

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there was a noticeable decrease in the rates of

adverse outcomes, conceivably related to

improved patient selection and increased

operator experience. 1 Owing to this

accumulating CAS experience, a better

understanding of the factors related to the

increased risk of adverse outcomes has been

possible. During the past 5 years, it has been

confirmed that patient-related factors such as

age, 2–5

symptom status, 2, 3

timing of

symptoms before CAS, 3–5

patient

comorbidities, 4, 6, 7

concurrent medications, 2

and smoking history 4 all might influence the

outcome. CAS outcomes are also impacted by

physician-related factors, including training

and experience, as well as hospital volume. 2

Furthermore, these factors are not yet well

characterized, while the progression in our

understanding of risk predictors and the

improvement of outcomes for CAS seem to

mirror the experience previously

demonstrated for CEA. 8 In the North

American Symptomatic Carotid

Endarterectomy Trial (NASCET),

contralateral occlusion was not excluded, but

it resulted in a 30-day risk of stroke and death

of 14.3%. Additionally, in the Asymptomatic

Carotid Atherosclerosis Study (ACAS), it led

to a 2% increase in stroke and death compared

with medical therapy. Since the publication of

these 2 trials, there has been a broad use of

CEA, including in patients with high surgical

risks, as a result of the extrapolation of the

outcomes of these studies. 9 CEA has been

revealed effective as the preventive treatment

for symptomatic and asymptomatic diseases. 1–3

CAS was introduced in 1994 and provides

another choice of treatment. There are

different results of randomized trials

comparing CAS with CEA for symptomatic

patients. 4–6

The Carotid Revascularization

Endarterectomy Versus Stenting Trial

(CREST) compared CAS with CEA in both

symptomatic and asymptomatic patients. 7

The aim of the present study was to analyze

the outcomes of CEA for physician- or site-

related variables associated with differential

outcomes for CAS.

METHODS

In this case series, 69 patients who underwent

angioplasty between Jun 2013 and June 2015

in our tertiary care center were enrolled. Two

methods of treatment are performed for

carotid stenosis (CS), namely CEA with

surgery or stenting through the femoral artery

access. 10

All the patients who underwent

carotid stenting were enrolled, and those with

intra-arterial coiling and angiography without

angioplasty were excluded. A large number of

studies have compared these 2 methods. 10

In

the present study, all the data on the patients

who underwent carotid angioplasty were

recorded regarding the presence of

neurological and clinical symptoms—whether

bilateral or ipsilateral—via Doppler

sonography. The success of treatment was

evaluated in terms of the patients’ recovery

and absence of symptoms as well as follow-

up outcomes by Doppler sonography. The

patients underwent carotid angiography and

carotid stenting 1 day after hospitalization,

and primary care and laboratory examination

were performed. In this study, the patients

who were diagnosed with CS via Doppler

sonography but did not show considerable

stenosis on angiography and had no need for

stenting were entirely excluded.


The Mann–Whitney U-test was used to

measure the relationship between the ordinal

and categorical variables. SPSS 18.0

(Chicago, USA) was used for all the statistical

analyses. The continuous and categorical

variables are presented as means ± standard

deviations (SDs) and percentages. The

Student t-test was utilized to compare the

quantitative variables, and the χ2 test was

applied to compare the categorical variables.

The 2 groups were compared using the

Pearson χ2

or the Fisher exact test for the

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39

categorical variables. A nonparametric test

(Kruskal–Wallis test) was employed to

remove the effect of the confounding factors

of the variables.

RESULTS

In this study, 69 patients (45 [65.2%] male

and 24 [24.8%] female) at a mean age of

63.85 ± 14.17 years were enrolled. The

patients were divided into 3 groups: 11

(15.9%) patients who showed occlusion

during the accidental assessment of their

carotid arteries, 50 (72.2%) patients who were

hospitalized due to cerebrovascular

accident/transient ischemic attack (CVA/TIA)

and were referred due to carotid occlusion,

and 8 (11.6%) cases with neurological

disorders who were hospitalized due to CS.

All the patients’ demographic and clinical

data are depicted in Table 1. The patients

were evaluated regarding their outcomes

during the 1st and 6th postprocedural months

via Doppler sonography and were

administered ASA (80 mg/d) and Plavix (75

mg/d) and then continued on ASA (80 mg/d).

Twenty-four (34.8%) cases had single right

CS, 23 (33.2%) had left CS, and 12 (17.4%)

had left and right stenoses. Two patients had

left or right CS concomitant with vertebral,

basilar, or subclavian stenosis. Six cases had

complete left or right CS without any flow in

addition to the severe stenosis of the other

side and 2 (2.9%) cases were hospitalized

owing to carotid dissection. The prevalence of

the patients according the location of their CS

is illustrated in Table 2. None of the patients

showed periprocedural complications such as

stroke, TIA, myocardial infarction, and

bleeding. Apropos delayed postoperative

complications, 2 (2.9%) cases suffered TIA,

but their stent was open; therefore, it does not

seem that it was related to the stent. With the

exception of 1 case with a pacemaker, all the

patients presented with sinus rhythm. As

regards stent stenosis, 4 (5.4%) cases had

mild stenosis (< 39%), 1 (1.4%) patient had

moderate stenosis (40%–69%), 2 (2.9%) cases

had severe stenosis (> 70%), and 1 (1.4%)

patient had dissection. The stenoses were

categorized as moderate to severe. Totally, 3

(4.5%) cases had moderate-to-severe stenosis

and 1 (1.4%) case had dissection;

nevertheless, none of the cases had CVA or

TIA. Typically, the stenosis was unilateral. In

3 (4.3%) patients who underwent angioplasty,

new stenosis was seen on the other side.

The patients with severe stent stenosis had a

history of CVA, and a significant relation

between stent restenosis and previous

CVA/TIA was found (P = 0.3). There was no

association between stent stenosis and the

side of stenting (P = 0.4). Stenting was

performed in the common carotid to the

eternal carotid in some of the patients; no

significant difference was seen between

restenosis and the length of the stent (P =

0.3). No significant relationship was also

found between hypertension (P > 0.05),

coronary artery disease (P = 0.6), diabetes

mellitus (P = 0.9), dyslipidemia (P > 0.05),

and smoking (P = 0.9). The result of the

multivariate analysis showed no association

between coronary artery disease,

dyslipidemia, hypertension, diabetes mellitus,

and age and CS (P = 0.9, P = 0.9, P = 0.5, P =

0.6, P = 0.8, and P = 0.1, respectively). The

relationships between the clinical data and

stent stenosis are shown in Table 3.

Table 1. Demographic and baseline clinical data

Variables N(%)

Male 54(65.2%)

Female 24(34.8%)

No symptoms 11(15.9%)

CVA/TIA 50(72.5%)

Neurological disorder 8(11.6%)

Right side 24(34.8%)

Left side 23(33.3%)

Right and left 12(17.4%)

R/L and vertebral or basilar 2(2.9%)

HTN 18(26.1%)

CAD 10(14.5%)

CS 3(4.3%)

R, Right; L, left; CVA, Cerebrovascular accident; TIA,

Transient ischemic attack; HTN, Hypertension; CAD,

Coronary artery disease; CS, Carotid stenosis

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Table 2. Complications and clinical data during and

after surgery or at follow-up

N (%)

Stent stenosis Mild Moderate Severe Dissection

4(5.8%) 1(1.4%) 2(2.9%) 1(1.4%)

Bilateral stent stenosis 1(1.4%)

Unilateral stent stenosis 7(10.1%)

No side 61(88.4%)

stenosis on contralateral side 3(4.3%)

Complications 1(1.4%)

Table 3. The relationship between the clinical and demographic data and stent stenosis

No Stenosis

Mild Stenosis

Moderate Stenosis

Severe Stenosis

P

Male 39 3 1 1 0.8

Female 22 1 0 1 0.8

CVA/TIA 45 3 1 0 0.03

Neurological disorder 6 0 0 2 0.03

No symptoms 10 1 0 0 0.03

Side before stenting

Right 22 1(1.4%) 0 0 0.4

Left 22 0 0 1(1.4%)

R+L 9 2(2.9%) 0 1(1.4%)

R/L+ vertebral of basilar 2(2.9%) 0 0 0

Stent stenosis, total occlusion 4 0 0 0

Dissection 61 4 1(1.4%)

CVA, Cerebrovascular accident; TIA, Transient ischemic attack; R, Right; L, Left A P value < 0.05 was considered the level of significance.

DISCUSSION

The CREST study showed that out of 2000

patients who underwent angioplasty or

endarterectomy, 120 cases developed

restenosis during 2 years of follow-up. In

these patients, hyperlipidemia and diabetes

mellitus were the causes of restenosis. The

stenosis was mostly seen in the 1st year of

follow-up. Another study defined the time

interval between the incidence of CVA and

the performance of clinical treatment as a

variable and suggested that angioplasty be

avoided during the acute phase of the disease.

Elsewhere, the rate of restenosis in patients

with diabetes mellitus and TIA was in line

with that in our study. We found no

significant relationships between age, diabetes

mellitus, and hyperlipidemia, which may be

due to our small sample size. 10

Previous investigations demonstrated that

CAS and CEA had comparable outcomes in

symptomatic and asymptomatic male and

female patients, although there was a lower

incidence rate of myocardial infarction

directly after CAS and a lower incidence of

stroke immediately after CEA. 11, 12

One

study reported that its older patients had a

better outcome after CEA, while its younger

patients had a slightly better outcome

following CAS. 13

Consequently, patients’

preferences and their age may be important

considerations in the choice of treatment for

CS. The relationship between advancing age

and increasing adverse events after CAS has

been highlighted previously 14, 5, 15

and the

effect of advancing age on treatment

differences, CAS versus CEA, was revealed

in the Stent-Protected Angioplasty versus

Carotid Endarterectomy (SPACE) trial.

The periprocedural safety outcomes for CAS

and CEA are the best stated to date for

patients with pre- and postprocedural medical,

neurological, ECG, and enzyme evaluations.

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An effective credentialing process for the

surgeon, rigorous training and credentialing

process for the interventionist, and increasing

integration of endovascular expertise might be

the reflection of these brilliant CREST

outcomes. 14

Advanced and supplementary

medical therapies that are commonly used

may also be an explanation for the favorable

outcomes observed after CEA in the CREST

study compared with outcomes in previous

randomized clinical trials of CEA. 9, 16 –19

Two analyses 16, 17

have confirmed the need

for prospective neurological evaluations

before and after CEA to best estimate the

outcome, with a 3-fold increase in events via

neurological assessment compared with

outcomes that were otherwise self-reported;

this is especially applicable since the

NASCET and ACAS trials used such

evaluations and constitute the basis for the

guidelines of the American Heart Association

(AHA). Likewise, it is remarkable that in the

original CAPTURE study, 20

CEA

adjudication led to the identification of 50%

more 30-day adverse outcome events

compared with the site-reporting of events

alone; thereby approving the importance of

both prospective data gathering and the

adjudication process in providing full

reporting of the outcomes. 9 In the present

study, no significant relationship was found

between neurological disorders and stent

stenosis (P > 0.05).

While there continues to be disagreement in

some circles regarding the actual definition of

high surgical risk, 21, 22

recent randomized

data have confirmed the perception vis-à-vis

the increase in stroke and death outcomes in a

predefined surgical population with both

physiological and anatomical surgical risks. 23

Nonetheless, in the 10 years since the

publication of the AHA’s guidelines, there

has not been a similarly rough demonstration

of the fulfillment of the guidelines in the

high-surgical-risk population undergoing

CEA. 9

CAS, when performed by experienced and

skilled interventionists, has patient outcomes

comparable to those of CEA performed by

experienced and skilled surgeons. During the

perioperative period, more incidences of

stroke arise after CAS. Younger patients have

a considerably better outcome with CAS and

older patients have a better outcome with

CEA. For the future, both CEA and CAS

appear to be suitable tools for preventing

stroke. In the present study, the rate of stent

stenosis in the patients with CS who were

hospitalized with CVA was higher than the

other outcome (P < 0.05). The results of our

study chime in with another investigation that

showed that the most significant cause of CS

was CVA/TIA. The rate of total occlusion in

our study was 5%–7%. Additionally, the rate

of postoperative complications was not

considerable. It has been suggested that

follow-up of the stenosis be continued on the

other side of the carotid artery. Six months’ or

yearly follow-up of the stented side has been

recommended.

In the current study, successful flow was

achieved by opening the occlusion in the

patients with severe stenosis. Nevertheless,

complete occlusion and concomitant absence

of flow was detected on the other side. No

treatment was performed while the other side

was reopened, and there was no complication

during surgery. Among our study population,

the most significant complications were CVA

and TIA; however, no myocardial infarction

and major and minor bleeding occurred. Our

results were in accordance with the outcomes

of other studies, although the procedures were

different. With regard to the patients’

recovery after surgery, almost 97% of the

cases recovered well. The remaining few

experienced delayed TIA after surgery.

Regarding the patients suffering mild and

severe stent stenosis, dissection was seen in 1

(1.4%) of the cases. One (1.4%) patient had

Takayasu’s arteritis and had a different

clinical outcome and showed bilateral

stenosis. Stent stenosis was mostly seen in the

patients who underwent stent implantation

due to CVA (P = 0.03). Thirteen of the cases

with CS had diabetes mellitus; no significant

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42

relationship was, however, found between

stent stenosis and diabetes mellitus (P > 0.05).

These results are not concordant with those

previously reported. Two (2.9%) cases were

assessed regarding dissection with no

significant stenosis.

In the CREST study, smoking was introduced

as the main risk factor in patients undergoing

endarterectomy. In contrast, in our study, no

significant relationship was found between

smoking and CS (P > 0.05). There was only a

significant relationship between the patients

with CVA/TIA and restenosis; this finding is

consistent with the results of the studies

reporting the occurrence of stenosis during

the 1st month of evaluation (P < 0.05). 10

Among the perioperative complications in our

study, there was 1 (1.4%) patient with TIA. In

the present study, all the implanted stents

were particularly bare-metal ones and the

results are similar to those of the previous

studies, although the latter investigations had

larger populations.

Limitations

The major limitation of the present study is

our small sample size, which underscores the

essential need for further research with a

greater sample size.

ACKNOWLEDGEMENTS

The authors express their gratitude to Dr

Mona Heidarali for her assistance in the

scientific writing of the manuscript.

Conflict of Interest: There was no conflict of

interest. This manuscript was financially

supported by a fund awarded by Iran

University of Medical Sciences, Tehran, I.R.

Iran.

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GS, Clark WM, Brooks W, et al. Stenting

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carotid-artery stenosis. N Engl J Med.

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Moore W, Meschia J, Hobson RW II, Brott

TG. Design of the Carotid Revascularization

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Patrick Verta. Thirty-Day Outcomes for

Carotid Artery Stenting in 6320 Patients From

2 Prospective, Multicenter, High-Surgical-

Risk Registries.; (Circ Cardiovasc Intervent.

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11. Brajesh K Lal, Kirk W Beach, Gary S Roubin,

Helmi L Lutsep, Wesley S Moore, Mahmoud

B Malas, et al. Restenosis after carotid artery

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12. Landesberg G, Shatz V, Akopnik I, Wolf YG,

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J, Gorter J, Algra A, et al. Long-term

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Carotid Endarterectomy Trial Collaborators.

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Ferguson GG, Haynes RB, et al. Benefit of

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20. Halliday A, Mansfield A, Marro J, Peto C,

Peto R, Potter J, et al. Prevention of disabling

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endarterectomy in patients without recent

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21. Gray WA, Yadav JS, Verta P, Scicli A,

Fairman R, Wholey M, et al. The CAPTURE

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22. Mozes G, Sullivan TM, Torres-Russotto DR,

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23. Boules TN, Proctor MC, Aref A, Upchurch

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24. Yadav JS, Wholey MH, Kuntz RE, Fayad P,

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Lavender on Anxiety and Pain in Angiography Ziyaeifard M, et al

44

Original Article Lavender on Anxiety and Pain in Angiography Ziyaeifard M, et al

Effects of Lavender Oil Inhalation on Anxiety and Pain in Patients

Undergoing Coronary Angiography

Mohsen Ziyaeifard

1, MD; Ali Zahedmehr

2, MD; Rasoul Ferasatkish

1, MD;

Zahra Faritous 1, MD; Mostafa Alavi

1, MD; Mahmoud Reza Alebouyeh

3, MD;

Ehsan Dehdashtian4, MD; Parisa Ziyaeifard

4, MD; Zeynab Yousefi*

5, MS

ABSTRACT

Background: Cardiovascular diseases alone account for 48% of deaths in the world. There is a high

rate of coronary angiography for the early diagnosis of such diseases. Not only do patients

suffer from anxiety because of the invasive nature of this procedure but also they experience

pain and discomfort for several hours after the procedure. We conducted this study to assess

the effects of the inhalation of lavender essential oil on anxiety and pain in patients

undergoing coronary angiography.

Methods: This clinical trial was performed at Rajaie Cardiovascular, Medical, and Research Center,

Tehran, Iran. Eighty patients who were hospitalized for coronary angiography participated

in this study. The patients were divided into 2 groups: control (n = 40) and intervention

(n=40). Data collection tools included the 3 forms of demographic information, standard

Spielberger questionnaire, and visual analog pain scale, which were completed by both

groups before and after aromatherapy with lavender oil. The collected data were analyzed

with SPSS software, version 16.0. (Armonk, NY, USA) using the χ2, McNemar, Wilcoxon,

Mann–Whitney, and t tests.

Results: The 2 groups were comparable apropos age, sex, marital status, and education level. After

aromatherapy, the level of anxiety in the intervention group decreased significantly

(P < 0.05) in comparison with the control group. Additionally, the extent of pain in the 2

groups showed a significant difference (P < 0.05).

Conclusions: Smelling the scent of lavender significantly reduced anxiety and pain in our patients,

before and after coronary angiography. (Iranian Heart Journal 2017; 18(1):44-50)

Keywords: Lavender, Anxiety, Pain, Coronary angiography

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. 3 Departments of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, I.R. Iran. 4 Medical Student; Faculty of Medicine, Iran University of Medical Sciences, Tehran, I.R. Iran. 5 MS in Critical Care; Dezful University of Medical Sciences, I.R. Iran.

*Corresponding Author: Zeynab Yousefi, MS in Critical Care; Dezful University of Medical Sciences, I.R. Iran.


Received: July 2, 2016 Accepted: November 11, 2016


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45

oday, the prevalence of cardiovascular

diseases has increased as a

consequence of changes in lifestyle,

advances in technology, alterations in eating

habits, smoking, aging, high blood pressure,

and lipid levels, all of which in turn lead to

diabetes. 1 Cardiovascular diseases are the

most important cause of mortality in the

world. 2 Given the life-threatening

characteristics of this disease and its

progressive course, it is necessary to use

diagnostic procedures such as angiography.

Despite its invasive nature, angiography is the

gold standard and an important diagnostic

procedure to determine the location and

severity of blood flow blockage in coronary

arteries. 3 Most of the invasive diagnostic

tests are accompanied by anxiety for patients.

Alongside diagnostic tests, hospitalization

creates different levels of anxiety for patients.

Patients’ non-acquaintance with the coronary

angiography procedure is one of the most

common causes of anxiety in these patients.

This lack of information leads to the

overstimulation of their nervous system. 4 A

previous study showed that 82 patients who

underwent coronary angiography had

experienced anxiety before the procedure. 5 In

order to prevent trauma to the arteries after

angiography, which may be caused by the

patients’ leg movement, an absolute bed rest

is required. It is recommended to use sand

bags weighing 2.5–4 kg around the procedure

area. As a consequence, back pain is common

among patients after coronary angiography

and it is usually accompanied by immobility

and limitation of movement. 6 According to a

study conducted in Iran, the incidence rate of

back pain in patients after coronary

angiography was 71.8%. 7 Both

pharmacological and non-pharmacological

methods have been used to reduce anxiety.

Among the non-pharmacological methods,

complementary therapies such as

aromatherapy have the benefits of being

inexpensive, noninvasive, easy to implement,

non-pharmacological in nature, and free from

chemical adverse effects. 8

Lavandula angustifolia Mill (lavender), which

is called ostokhodos in Iran, is a strong

aromatic agent. 9 This plant belongs to the

Lamiaceae family and is herbaceous,

aromatic, and evergreen. Lavender plants are

widely used in Iranian traditional medicine.

They possess sedative and analgesic effects,

confirmed by Iranian scientists such as Abu

Ali Sina (Avicenna) and Razi (Rhazes). 10

We

conducted the present study to evaluate the

effects of lavender oil inhalation on anxiety

and pain in patients undergoing coronary

angiography.

METHODS

This randomized double-blinded clinical trial

was performed at Rajaie Cardiovascular,

Medical, and Research Center, Tehran, Iran.

All patients who were admitted between

August 2014 and April 2015 for coronary

angiography were enrolled in this study.

Eighty patients were eligible for this study

after meeting the inclusion criteria,

comprising age between 25 and 75 years,

coronary angiography for the 1st time,

complete consciousness, no history of taking

psychiatric drugs, no history of pulmonary or

liver insufficiency, allergies, and asthma. All

the patients filled out a written consent form

to participate in this study. The patients were

enrolled in the study according to the table of

a computerized randomization list: control

(n = 40) and intervention (n = 40). The data

encompassed demographic information,

Spielberger standard questionnaire to measure

anxiety, and visual analogue pain scale. The

data were collected by a trained nurse, who

was blinded to the study. The Spielberger

questionnaire test consists of 2 separate parts,

both parts containing 20 items. The 1st and

2nd parts determine state and trait anxiety,

respectively. The feeling of anxiety at the

moment is called state anxiety, whereas

overall feeling of anxiety during a period is

referred to as trait anxiety. The total scores of

both state and trait anxiety scales are in the

range of 20–80. Patients with total scores > 43

T

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46

are considered anxious. This questionnaire is

widely used by psychologists and

psychiatrists. The validity and reliability of its

Farsi translation were reviewed and approved

by Shahid Beheshti University and Tehran

Psychiatric Institute. 8 The Spielberger

questionnaires were completed for all the

patients 1 hour before angiography. Before

the procedure, the patients in the intervention

group smelled a piece of cotton wool soaked

in 5 drops of lavender essential oil, at a

distance of 5 cm from the nose with deep

inhalations for 5 minutes. The control group

smelled a piece of cotton wool soaked in

distilled water in the same manner. The

physician and the nurse were blinded to the

contents of the vials. Thirty minutes later, the

Spielberger questionnaires were completed

again. Thereafter, all the patients underwent

coronary angiography. One hour after the

procedure, pain was measured in all the

patients using the visual analogue pain scale.

The interventions were subsequently

performed on the patients again. Thirty

minutes later, pain scoring was assessed using

the visual analogue pain scale in all the

patients. During the study period, none of the

patients met the exclusion criteria, including

refusing to give consent to continue the study,

having any symptoms of myocardial

infarction, and allergy.

RESULTS

The collected data were analyzed using IBM

SPSS Statistics for Windows, version 16.0

(Armonk, NY, USA). The χ2 test revealed no

significant differences between the 2 groups

in terms of age, sex, marital status, and

education level. State and trait anxiety levels

in the patients are depicted in Table 2 and

Table 3.

Table 1. Review of the homogeneity of the demographic characteristics

Demographic Characteristics P

Sex 0.11

Intervention Group Number (%)

Control Group Number (%)

Male Female Male Female

14 (35) 26 (65) 22 (55) 18 (45)

Marital Status 0.09

Intervention Group Number (%)


Single Married Single Married

35 (87.5) 5 (12.5) 28 (70) 12 (30)

Education Level Intervention Group Number (%)


0.87 Less than diploma 21(52.5) 20 (50)

High school diploma 9 (22.5) 11 (27.5)

University degree 10 (25) 9 (22.5)

Age 0.31

Intervention Group Mean

Control Group Mean

50.48 51.30

Table 2. State and trait anxiety of the control group before and after the inhalation of distilled water

State Anxiety in the Control Group P

Before Intervention After Intervention

0.68 Anxious Non-Anxious Anxious Non-Anxious

Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage

28 70 12 30 26 65 14 35

Trait Anxiety in the Control Group

0.68


Anxious Non-Anxious Anxious Non-Anxious Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage

28 70 12 30 26 65 14 35

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Table 3. State and trait anxiety of the intervention group before and after the inhalation of lavender essential oil

State Anxiety in the Intervention Group P


0.001 Anxious Non-Anxious Anxious Non-Anxious

Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage

30 75 10 25 8 20 32 80

Trait Anxiety in the Intervention Group

0.001 Before Intervention After Intervention

Anxious Non-Anxious Anxious Non-Anxious Frequency Percentage Frequency Percentage Frequency Percentage Frequency Percentage

27 67.5 13 32.5 14 35 26 65

Feeling of pain was reduced dramatically in the intervention cases (Table 4).

Table 4. Pain assessment in the participants before and after the inhalation of lavender oil or distilled water

Control Group P


Pain Intensity Percent in Group Pain Intensity Percent in Group

Mild 30 Mild 30 0.96 Moderate 30 Moderate 33

Severe 40 Severe 37

Total 100 Total 100

Intervention Group P-Value


Pain Intensity Percent in Group Pain Intensity Percent in Group

Mild 30 Mild 55 0.001 Moderate 30 Moderate 42.5

Severe 40 Severe 2.5

Total 100 Total 100

DISCUSSION

Coronary angiography is an invasive

procedure that creates pain and anxiety for

patients.11

Hospitalization and waiting for the

procedure are the main causes of anxiety in

these patients. Healthcare professionals

should identify patients’ anxiety and try to

prevent or relieve it. 12

Both pharmacological

and non-pharmacological methods are usually

drawn upon to reduce anxiety. In the current

study, the effects of lavender oil were

assessed on the perception of anxiety and pain

in patients candidated for coronary

angiography. The results showed that

smelling lavender essential oil reduced

anxiety and pain before and after coronary

angiography. Based on the results, 70%–75%

of our patients experienced state anxiety

before coronary angiography, which is

compatible with previous studies. 3, 13

We also found a reduction in the state and

trait anxiety levels after aromatherapy in the

intervention group. Mirzaei et al 14

showed

that lavender aromatherapy was able to

decrease anxiety and plasma concentrations of

cortisol in nulliparous women during labor.

Shiina et al 15

reported the relaxation effects

of lavender aromatherapy on improving

coronary artery blood flow in their study.

Elsewhere, Muzzarelli et al 16

concluded that

there was a statistically significant difference

in anxiety before and after aromatherapy in

their intervention group. Based on another

study by Karadag et al, 17

lavender essential

oil aromatherapy improved sleep quality and

decreased anxiety of patients who were

hospitalized in the coronary care unit. The

results of a study by Kim et al 18

revealed

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decreased opioid requirements of patients

after laparoscopic adjustable gastric banding

(LAGB) as a consequence of postoperative

lavender aromatherapy. Likewise, Karaman et

al 19

showed that aromatherapy with lavender

essential oil had a significant effect on

reducing anxiety and pain associated with

peripheral venous cannulation in patients

undergoing surgery. In a study by Hasanzadeh

et al, 20

24 hours after coronary artery bypass

grafting, the patients’ perception of pain and

anxiety during chest tube removal decreased

dramatically as a result of lavender oil

aromatherapy. In light of these studies and the

results of the present one, it can be concluded

that by stimulating the olfactory tract,

lavender scent affects the hypothalamus and

leads to a decrease in corticotropin releasing

hormone. As a result, the pituitary gland

secrets less adrenocorticotropic hormone,

which can cause a reduction in the cortisol

level. 21

Lavender contains linalool, ketone, and

alcohol. Ketones reduce pain and

inflammation effectively and have soporific

effects. 22

Ericksen 23

also stated that lavender

as cold compress on the forehead had anti-

fatigue and refreshing effects.

The analgesic properties of lavender essential

oil can be attributed to the fact that it can

stimulate the olfactory bulb and, thus, confer

relaxation. 9 All the results from the

aforementioned studies are in accordance with

the results of the present study. The analgesic

mechanism of this essential oil is not fully

understood. However, inhaling 1,8-cineol,

which is one of the ingredients of lavender

essential oil, can block the production of pain

mediators such as prostaglandins and

leukotrienes via inhibiting arachidonic acid

metabolism. 24

CONCLUSIONS

Overall, the results of the current study

indicated that most of the patients suffered

from high levels of anxiety before coronary

angiography. Accordingly, in order to prevent

this undesirable feeling and its adverse

complications, aromatherapy can be used as

complementary therapy to reduce the anxiety

and improve vital signs of patients before

undergoing coronary angiography. Given the

advantages of lavender essential oil

aromatherapy as a simple, inexpensive, safe,

and noninvasive method, it is recommended

that this drug-free approach be used to reduce

anxiety in patients before invasive diagnostic

procedures.

Limitations

The major limitation of the present

investigation is that it was a single-center

study. Needless to say, multicenter studies

with more patients will yield more powerful

results.

Conflict of Interest: All the authors of the

present study confirm that they have no

conflict of interests to disclose regarding the

publication of the manuscript or an institution

or product that is mentioned in the manuscript

and/or is important to the outcome of the

study presented.

REFERENCES

1. Cho M-Y, Min ES, Hur M-H, Lee MS. Effects

of Aromatherapy on the Anxiety, Vital Signs,

and Sleep Quality of Percutaneous Coronary

Intervention Patients in Intensive Care Units.

Evidence-Based Complementary and

Alternative Medicine. 2013:6.

2. MeharanFard S, Abdollahi A, Behnampour N,

Kordnejad A. Correlated Factors with Back

Pain in Patients after Coronary Angiography.

Journal of Research Development in Nursing

& Midwifery. 2012;9(2):20-6.

3. Majidi S. Recitation effect of holy Quran on

anxiety of patients before undergoing

coronary artery angiography. Journal of

Guilan University of Medical Sciences.

2004;13(49):61-7.

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4. Haneafy N, Ahmadi F, Memariyan R. Effects

of relaxation Benson method on conditions

hemodynamic in patients undergoing coronary

angiography. Persian Yazd J Res Med Sci.

2004;12(4):78-85.

5. Khayyam Nekouei Z, Yousefy A, Nickneshan

S. Comparing anxiety in cardiac patients

candidate for angiography with normal

population. ARYA Atheroscler. 2011;7(2):93-

6.

6. Pollard S, Munks K, Wales C, Crossman D,

Cumberland D, Oakley G, et al. Position and

Mobilisation Post-Angiography Study

(PAMPAS): a comparison of 4.5 hours and

2.5 hours bed rest. Heart. 2003;89(4):447-8.

7. Rezaei‐Adaryani M, Ahmadi F, Mohamadi E,

Asghari‐Jafarabadi M. The effect of three

positioning methods on patient outcomes after

cardiac catheterization. Journal of advanced

nursing. 2009;65(2):417-24.

8. Tahmasbi H, Mahmoodi G, Mokhberi V,

Hassani S, Akbarzadeh H, Rahnamai N. The

impact of aromatherapy on the anxiety of

patients experiencing coronary angiography.

Zahedan Journal of Research in Medical

Sciences. 2012;14(3):51-5.

9. Soltani R, Soheilipour S, Hajhashemi V,

Asghari G, Bagheri M, Molavi M. Evaluation

of the effect of aromatherapy with lavender

essential oil on post-tonsillectomy pain in

pediatric patients: a randomized controlled

trial. International journal of pediatric

otorhinolaryngology. 2013;77(9):1579-81.

10. Jahdi F, Sheikhan F, MARGHATI KE,

Haghani H. The effect of lavender essence on

the post-episiotomy pain intensity of

perineum. Journal of Sabzevar University of

Medical Sciences. 2009;3(16):127-33.

11. Taylor-Piliae RE. The effect of nursing

interventions utilizing music therapy or

sensory information on Chinese patients’

anxiety prior to cardiac catheterization: A

pilot study. European Journal of

Cardiovascular Nursing. 2002;1(3):203-11.

12. Dogan MV, Senturan L. The effect of music

therapy on the level of anxiety in the patients

undergoing coronary angiography.

2012;2(3):165-9.

13. Uzun S, Vural H, Uzun M, Yokusoglu M.

State and trait anxiety levels before coronary

angiography. Journal of clinical nursing.

2008;17(5):602-7.

14. Mirzaei F, Keshtgar S, Kaviani M, Rajaeifard

A. The effect of lavender essence smelling

during labor on cortisol and serotonin plasma

levels and anxiety reduction in nulliparous

women. Journal of Kerman University of

Medical Sciences. 2009;16(3):245-54.

15. Shiina Y, Funabashi N, Lee K, Toyoda T,

Sekine T, Honjo S, et al. Relaxation effects of

lavender aromatherapy improve coronary flow

velocity reserve in healthy men evaluated by

transthoracic Doppler echocardiography.

International journal of cardiology.

2008;129(2):193-7.

16. Muzzarelli L, Force M, Sebold M.

Aromatherapy and reducing preprocedural

anxiety: A controlled prospective study.

Gastroenterology Nursing. 2006;29(6):466-71.

17. Karadag E, Samancioglu S, Ozden D, Bakir E.

Effects of aromatherapy on sleep quality and

anxiety of patients. Nursing in critical care.

2015.

18. Kim JT, Ren CJ, Fielding GA, Pitti A, Kasumi

T, Wajda M, et al. Treatment with lavender

aromatherapy in the post-anesthesia care unit

reduces opioid requirements of morbidly

obese patients undergoing laparoscopic

adjustable gastric banding. Obesity surgery.

2007;17(7):920-5.

19. Karaman T, Karaman S, Dogru S, Tapar H,

Sahin A, Suren M, et al. Evaluating the

efficacy of lavender aromatherapy on

peripheral venous cannulation pain and

anxiety: A prospective, randomized study.

Complementary therapies in clinical practice.

2016;23:64-8.

20. Hasanzadeh F, Kashouk NM, Amini S, Asili

J, Emami SA, Vashani HB, et al. The effect of

cold application and lavender oil inhalation in

cardiac surgery patients undergoing chest tube

removal. EXCLI Journal. 2016;15:64-74.

21. Gedney JJ, Glover TL, Fillingim RB. Sensory

and affective pain discrimination after

inhalation of essential oils. Psychosomatic

Medicine. 2004;66(4):599-606.

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22. Seraji A, Vakilian K. The comparison

between the effects of aromatherapy with

lavender and reathing techniques on the

reduction of labor pain. Complementary

Medicine Journal of faculty of Nursing &

Midwifery. 2011;1(1):34-41.

23. Ericksen M. Aromatherapy For Childbearing.

Mothering Summer. 1994.

24. Santos F, Rao V. Antiinflammatory and

antinociceptive effects of 1, 8-cineole a

terpenoid oxide present in many plant

essential oils. Phytotherapy research.

2000;14(4):240-4.

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Percutaneous Coronary Intervention and Pulmonary Balloon Valvuloplasty in a Patient With Severe Valvular Pulmonary Stenosis Firouzi, et al

51

Case Report Percutaneous Coronary Intervention and Pulmonary Balloon Valvuloplasty in a Patient With Severe Valvular Pulmonary Stenosis Firouzi, et al

Percutaneous Coronary Intervention and Pulmonary Balloon

Valvuloplasty in a 56-Year-Old Woman With Severe Valvular

Pulmonary Stenosis: A Case Report

Ata Firouzi1, MD; Omid Shafe*

1, MD;

Farzad Kamali2, MD; Foroozan Asgari

2, MS

ABSTRACT

Percutaneous balloon pulmonary balloon valvuloplasty is the treatment of choice among patients

with severe pulmonary stenosis. We describe a 56-year-old woman with severe pulmonary stenosis

who presented with hemodynamic disturbances due to pulmonary thromboembolism during

hospitalization.

Percutaneous pulmonary balloon valvuloplasty is a safe and effective treatment for valvular

pulmonary stenosis. (Iranian Heart Journal 2017; 18(1):51-55)

Keywords: Severe valvular pulmonary stenosis, Percutaneous coronary intervention,

Pulmonary balloon valvuloplasty

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: Omid Shafe, MD; Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, I

I.R. Iran. E-mail: [email protected] Tel: 02123922088

Received: May 30, 2016 Accepted: August 25, 2016

alloon valvuloplasty for isolated

valvular pulmonary stenosis (PS)

provides nearly equivalent long-term

gradient relief with less valvular insufficiency

and less late ventricular ectopic activity than

surgery. 1, 2, 3

This report illustrates

percutaneous coronary intervention on a

totally occluded left anterior descending

coronary artery (LAD) and simultaneous

percutaneous pulmonary balloon

valvuloplasty in a 56-year-old woman.

CASE REPORT

A 56-year-old hypertensive woman with

valvular PS presented with progressive

dyspnea (functional class II–III) and typical

chest pain of 2 months’ duration. She was

referred to our center for further diagnostic

and therapeutic investigation. On physical

examination, her vital signs were normal. The

jugular venous pressure was raised, and there

was a prominent left sternal border lift.

Auscultation revealed a wide S2 splitting as

well as a mid-systolic murmur with moderate

intensity (ie, 3/6).

On echocardiography, there were

biventricular failure (left ventricular ejection

fraction = 25%), severe right ventricular

enlargement, severe tricuspid regurgitation

with a trans-regurgitation gradient of 115 mm

Hg, and a severe valvular PS (peak pressure

gradient = 120 mm Hg). The pulmonary valve

annulus was measured at 22 mm (Fig. 1).

B

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Figure 1. (Left) Transthoracic echocardiography (TTE) in the continuous wave Doppler mode shows a

severe valvular pulmonary stenosis with a 130-mm Hg transvalvular gradient before balloon valvuloplasty. (Right) TTE in the continuous wave Doppler mode shows a nonsignificant residual pulmonary stenosis with a peak pressure gradient of about 20 mm Hg after balloon valvuloplasty.

Coronary angiography showed the occlusion

of the LAD from the ostium with a good

distal runoff.

During hospitalization, the patient became

thermodynamically unstable. She became

hypotensive and unconscious. Pulmonary

computed tomography angiography was

performed and it showed segmental

pulmonary thromboembolism PTE.

The estimated risk of surgery was high;

therefore, we opted for medical treatment.

After a 4-day supportive therapy, her

hemodynamic instability improved and we

decided to perform percutaneous coronary

intervention and valvuloplasty (Fig. 2).

Figure 2. (Left) Selective coronary angiography in the right anterior oblique (RAO) caudal

view shows a totally occluded left anterior descending coronary artery (LAD) from the ostial part with a faint antegrade runoff. (Right) Selective coronary angiography in the RAO view after successful percutaneous coronary intervention on the LAD.

PROCEDURE AND RESULT

The wiring of the stenotic pulmonary valve

proved extremely challenging as it was

heavily calcified and severely stenotic (Fig.

4). Multiple attempts were made to cross the

wire, and finally a 0.035-inch straight wire

was passed through the stenotic valve. As the

wire passed through the stenosis, we found

slight systemic hypotension, which was a sign

for a high-risk situation and a very severe

stenosis. Passing a multipurpose A1 catheter

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(6F size) caused more systemic hypotension

(135/80 to 95/60 mm Hg). A severe peak-to-

peak pressure gradient of about 100 mm Hg

was measured between the right ventricle and

the right atrium. After exchanging the non-

stiff 0.035 wire with a stiff one, we utilized 2

different balloons for valvuloplasty to reduce

the risk of procedural complications. The 1st

balloon was an 8–40 Nucleus balloon used for

predilation, followed by a 26–40 balloon to

wrap up valvuloplasty. We inflated the 1st

balloon twice, and there was a waist showing

significant stenosis. The 2nd balloon was

inflated 3 times, and the waist was eliminated

after inflation (Fig. 5). Deep hypotension

occurred during inflation; we, therefore,

minimized the whole time of the crossing,

inflating, and deflating of the balloons to less

than 8 seconds. After valvuloplasty, we found

that there was a 25 mm Hg peak-to-peak

pressure gradient between the right ventricle

and the pulmonary artery, which was the

effect of infundibular stenosis due to severe

right ventricular hypertrophy. Our final right

ventricular injection proved the infundibular

hypertrophy, so we considered a saline bolus

injection so as to reduce this effect. Much as

we expected hypotension due to the

infundibular hypertrophy, it did not occur

during the course of hospitalization after the

procedure. Postprocedural echocardiography

showed a left ventricular ejection fraction of

about 30%, thickened and dome-shaped

pulmonary valve leaflets with moderate

pulmonary insufficiency, and no significant

transvalvular stenosis with a peak pressure

gradient of 20 mm Hg (Fig. 2).

Finally, the patient was discharged in good

condition with antiplatelet and heart failure

medications. Two months after balloon

valvuloplasty and percutaneous coronary

intervention, her symptoms were significantly

relieved and follow-up transthoracic

echocardiography showed a left ventricular

ejection fraction of 35%, moderate right

ventricular enlargement with mild-to-

moderate right ventricular systolic

dysfunction, trivial tricuspid regurgitation,

and moderate pulmonary insufficiency with

no significant residual PS (pulmonary

pressure gradient = 12 mm Hg).

Figure 4. Right ventricular injection with a pigtail catheter shows

severe right ventricular enlargement, thickened pulmonary valve leaflets, severe valvular stenosis, and post-stenotic dilatation.

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Figure 5. Pulmonary balloon valvotomy with a 26-40 balloon.

DISCUSSION

PS is a relatively common congenital defect

that occurs in approximately 10% of children

with congenital heart diseases. It is usually

associated with a benign clinical course, and

there is, therefore, a high rate of survival to

adulthood. The common cause of valvular PS

is congenital, and acquired causes are rare. 4, 5

Patients with congenital valvular PS

undergoing balloon valvuloplasty have a low

rate of restenosis. 6

Balloon valvuloplasty is recommended in

asymptomatic patients with a dome-shaped

pulmonary valve and a peak instantaneous

Doppler pressure gradient > 60 mm Hg or a

mean pressure Doppler gradient > 40 mm Hg.

This modality is also recommended in

symptomatic patients with a dome-shaped

pulmonary valve and a peak instantaneous

Doppler pressure gradient > 50 mm Hg or a

mean pressure Doppler gradient > 30 mm Hg.

Balloon valvuloplasty is not recommended for

asymptomatic patients with a peak

instantaneous gradient by Doppler < 50 mm

Hg in the presence of normal cardiac output,

for symptomatic patients with PS and severe

pulmonary regurgitation, and for symptomatic

patients with a peak instantaneous pressure

gradient by Doppler < 30 mm Hg. 7

According to the indications noted above, our

patient could be treated surgically or via an

interventional approach. The EuroSCORE for

this patient was estimated to be 7, which

means a high risk of surgery. Accordingly,

our cardiac surgeons decided not to go on

with the surgical approach.

Given the severity of the PS, crossing the

lesion was very challenging. Finally, we

managed to cross a straight-tipped wire

through the pulmonary valve, which resulted

in a drop in blood pressure. This was another

sign for the severity of the PS in the patient.

This phenomenon is known in severely

stenosed aortic valve as “the Brockenbrough-

Braunwald-Morrow sign”. We minimized the

balloon inflation time to avoid cardiovascular

collapse. Also, according to the

recommendations, the size of balloons used

for valvuloplasty in PS should be chosen at

least 120% larger than the pulmonary valve

annulus diameter. 8

Consequently, we used a

26-40 balloon for valvuloplasty (pulmonary

valve annulus diameter was 22 mm), after

predilation with a smaller size balloon (8-40)

to reduce the probability of valve rupture and

minimize the time of balloon inflation. As

was mentioned before, because of the very

severe stenotic pulmonary valve and difficulty

in crossing the wire, the evaluation of the

pressure gradient between the pulmonary

artery and the right ventricle could not be

performed simultaneously because one should

pull back an end-hole catheter through a

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stenotic valve to detect the pressure gradient.

After the dilation of the pulmonary valve, we

encountered a residual pressure gradient due

to right ventricular outflow tract hypertrophy,

which had been diagnosed before the

procedure via echocardiographic evaluation,

and a drop in blood pressure as its

consequence. There was about a 30 mm Hg

residual pressure gradient after balloon

dilation, but no drop in blood pressure was

detected, although we administered a saline

injection and beta-blockers to prevent this

situation. Nonetheless, there is an unresolved

question as to the diagnosis of pulmonary

thromboembolism in this patient inasmuch as

she had severe PS and small amounts of clot,

which can cause complete obstruction in the

right ventricular outflow tract and

cardiovascular collapse. Whether or not this

thrombosis was in situ or was embolized has

remained unclear and needs further

observations.

REFERENCES

1. Lin SC, Huang JJ, Hsu Kl, Balloon

valvuloplasty in adult with congenital

valvular pulmonary stenosis. Actacardiol Sin

2004;20:147-53

2. O’ Connor BK, Beekman RH. Intermediate

term Outcome after balloon valvuloplasty:

comparison with a matched surgical control

group. JACC. July 1992;20:169-73

3. Miller GAH Balloon

valvuloplastyandangioplastyin congenital

heart disease. Br Heart J 1985; 54:285-9

4. Compball M. Factors in the etiology of

pulmonary stenosis.Br Heart J. 1962

September; 24(5): 625–632.

5. Snellen HA, Hartman H Buis-Liem TN, et al.

Pulmonic stenosis. Circulation 1968;38:93-

101.

6. P S Rao, O Galal. M Patnana. Result of 3 to

10 year follow up of balloon dilatation of

pulmonary valve. Haert 1998; 80:591-595

7. Warnes CA, Williams RG, Bashore TM, et al.

ACC/AHA 2008 Guidelines for the

Management of Adults with Congenital Heart

Disease: a report of the American College of

Cardiology/American Heart Association Task

Force on Practice Guidelines (writing

committee to develop guidelines on the

management of adults with congenital heart

disease). Circulation 2008; 118:e714.

8. Mc Crindle BW, Kan JS. Kan. Long term

results after pulmonary valvuloplasty.

Circulation 1991; 83:1915-22.

../../Users/Users/farzad/Desktop/UpToDate20.2/contents/mobipreview.htm









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Background, Methods, Results, and

Conclusions. Abstracts for case

reports and correspondences should

not be structured and must be shorter

(50 to 75 words). Include keywords at

the end of the abstract.

Text should be organized as follows:

Introduction, Methods, Results,

Discussion, and Conclusion. Methods

should include the statistical analysis.

Cite references, illustrations, and

tables in numeric order in the text.

Give all measurements and weights in

standard metric units. Credit suppliers

of drugs, equipment, and other brand-

name material mentioned in the article

in parentheses, giving company name

and location.

Acknowledgements All contributors

who do not meet the criteria for

authorship may be mentioned in the

acknowledgements section. It should

include persons who provided

technical help, writing assistance, and

departmental supervision who only

provided general support. Financial

and material support should also be

acknowledged.

Conflict of interest Authors must

acknowledge and declare any sources

of funding and potential conflicting

interest, such as receiving funds or

fees by, or holding stocks and shares

in, an organization that may profit or

lose through the publication of the

paper. Declaring a competing interest

will not lead to the automatic rejection

of the paper.

Ethical guidelines must be addressed

in the Materials and Methods section.

(1) Please state that informed consent

was obtained from all human adult

participants and from the parents or

legal guardians of minors. Include the

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name of the appropriate institutional

review board that approved the

project. (2) Indicate in the text that the

maintenance and care of experimental

animals complies with National

Institutes of Health guidelines for the

humane use of laboratory animals, or

those of your institute or agency.

References should be identified by

using superscript numbers without

changing the font size (e.g.,1,2,3

). Do

not cite personal communications,

manuscripts in preparation, or

unpublished data. Type the references

double spaced on a separate sheet and

number consecutively in the order in

which they are mentioned in the text.

List all authors if 6 or fewer;

otherwise list the first 6 and add et al.

Style and punctuation of references

should conform to the Vancouver style

or the Index Medicus format as in the

examples below:

Journal articles:

1. Burt VL, Cutler JA, Higgins M, Horan

MJ, Labarthe D, Whelton P, et al.

Trends in the prevalence, awareness,

treatment and control of hypertension

in the adult US population.

Hypertension 1995; 26: 60-69.

Chapters in books:

2. Ross DN, Martelli V, Wain WH:

Allograft and autograft valves used for

aortic valve replacement. In: Ionescu

MI, (ed.). Tissue Heart Valves.

London: Butterworth, 1979: pp. 319-

29.

Tables should be typed double spaced

on separate sheets, each with a table

number and title above the table and

explanatory notes and legends below.

Tables should be self-explanatory and

the data should not be duplicated in

the text or figures. If tables provide

repetitive information, they will be

deleted.

Legends to illustrations should be

typed double spaced on a separate

sheet. Numbers should correspond to

the order in which they appear in the

text. Give the type of stain and

magnification power for

photomicrographs. Patients should not

be recognizable in illustrations unless

written consent is supplied.

Illustrations should be submitted

digitally (preferable), or in 3 sets of

glossy prints. High-quality laser

artwork is also acceptable, but

photocopies are not. Write the first

author’s last name, figure number, and

an arrow indicating the top of the

figure on the back of each illustration

in pencil. All illustrations will be

published in black and white unless

color prints are specifically requested

by the author(s). The author must be

prepared to pay a fee for publication

of color photographs.

Reprints: Reprints can be ordered at

an extra charge. Contact the Editorial

Office for details.

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Electronic manuscripts

All authors are strongly encouraged to

submit their manuscripts via e-mail using

Microsoft Office Word (2003 or afterward) in

order to allow more rapid editing and

preparation for publication. The author

should retain copies of all files as backup. E-

mails should bear the author’s name, short

title of the article, and operating system used.

All manuscripts and correspondences

should be submitted to:

Hussein Tabatabaei, M.D.

Editor-in-Chief

Iranian Heart Association Journal

P. O. Box: 15745-1341

Tehran 19974 Iran

Tel: (009821) 22048174

Fax: (009821) 22048174

E-mail: [email protected]


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Forthcoming Meetings

Master Class on Aortic Valve Repair: A Step-by-Step Approach Wednesday, March 22, 2017 to Friday, March 24, 2017 L'Institut Mutualiste Montsouris (IMM) Paris France See map: Google Maps 13th International Congress of Update in Cardiology and Cardiovascular Surgery Thursday, March 23, 2017 to Sunday, March 26, 2017 Cesme Sheraton Convention Center Izmir Turkey See map: Google Maps The 25th Annual Meeting of the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS 2017) Thursday, March 23, 2017 to Sunday, March 26, 2017 Coex Convention and Exhibition Center Seoul South Korea See map: Google Maps Thoracic Surgery: Part I Monday, March 27, 2017 to Friday, March 31, 2017 EACTS House Windsor United Kingdom See map: Google Maps Symposium on Robotic Mitral Valve Repair Friday, March 31, 2017 to Saturday, April 1, 2017 Loews Chicago Hotel Chicago, IL United States See map: Google Maps Donor Heart and Lung Procurement Simulation Lab sponsored by UPMC Monday, April 3, 2017 The Center for the Future of Surgery, UCSD La Jolla, CA United States See map: Google Maps Houston Methodist CMR Workshop Monday, April 3, 2017 to Friday, April 7, 2017 Houston Methodist Hospital Houston, TX United States

See map: Google Maps Cardiomersion 2017 Tuesday, April 4, 2017 to Wednesday, April 5, 2017 Menoufia University Egypt Cairo Egypt See map: Google Maps 23th Annual Conference of the Egyptian Society of Cardiothoracic Surgery Tuesday, April 4, 2017 to Thursday, April 6, 2017 Mena House Hotel, Giza, Egypt Cairo Egypt See map: Google Maps Re-Evolution Summit - MICS Thursday, April 6, 2017 to Friday, April 7, 2017 Houston Methodist Research Institute Houston, TX United States See map: Google Maps Toronto Anesthesia Symposium Saturday, April 8, 2017 to Sunday, April 9, 2017 MaRS Discovery District- 101 College Street Toronto, ON Canada See map: Google Maps 11th World Congress on Pediatric Cardiology and Congenital Cardiovascular Disease Tuesday, April 18, 2017 to Wednesday, April 19, 2017 Doubletree by Hilton Hotel London - Ealing London United Kingdom See map: Google Maps ESTS Skill Track Course "Elancourt in Copenhagen" Wednesday, April 19, 2017 to Friday, April 21, 2017 Denmark See map: Google Maps 32nd EACTA Annual Congress 2017 Wednesday, April 19, 2017 to Friday, April 21, 2017 Maritime Hotel Berlin Germany See map: Google Maps

https://www.ctsnet.org/events/master-class-aortic-valve-repair-step-step-approach

https://www.ctsnet.org/events/master-class-aortic-valve-repair-step-step-approach

http://maps.google.fr/?q=L%27Institut+Mutualiste+Montsouris+%28IMM%29%2C+Paris%2C+%2C+fr

https://www.ctsnet.org/events/13th-international-congress-update-cardiology-and-cardiovascular-surgery

https://www.ctsnet.org/events/13th-international-congress-update-cardiology-and-cardiovascular-surgery

https://www.ctsnet.org/events/25th-annual-meeting-asian-society-cardiovascular-and-thoracic-surgery-ascvts-2017



https://www.ctsnet.org/events/thoracic-surgery-part-i-1

https://www.ctsnet.org/events/symposium-robotic-mitral-valve-repair

https://www.ctsnet.org/events/donor-heart-and-lung-procurement-simulation-lab-sponsored-upmc

https://www.ctsnet.org/events/donor-heart-and-lung-procurement-simulation-lab-sponsored-upmc

https://www.ctsnet.org/events/houston-methodist-cmr-workshop

https://www.ctsnet.org/events/cardiomersion-2017

https://www.ctsnet.org/events/23th-annual-conference-egyptian-society-cardiothoracic-surgery

https://www.ctsnet.org/events/23th-annual-conference-egyptian-society-cardiothoracic-surgery

https://www.ctsnet.org/events/re-evolution-summit-mics

https://www.ctsnet.org/events/toronto-anesthesia-symposium

https://www.ctsnet.org/events/11th-world-congress-pediatric-cardiology-and-congenital-cardiovascular-disease

https://www.ctsnet.org/events/11th-world-congress-pediatric-cardiology-and-congenital-cardiovascular-disease

https://www.ctsnet.org/events/ests-skill-track-course-elancourt-copenhagen

https://www.ctsnet.org/events/ests-skill-track-course-elancourt-copenhagen

https://www.ctsnet.org/events/32nd-eacta-annual-congress-2017

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12th Vienna Interdisciplinary Symposium on Aortic Repair (VISAR) Thursday, April 20, 2017 to Friday, April 21, 2017 Ritz-Carlton Hotel Vienna Austria See map: Google Maps AATS Mitral Conclave Thursday, April 27, 2017 to Friday, April 28, 2017 New York Hilton Midtown New York, NY United States See map: Google Maps AATS Innovation Summit Saturday, April 29, 2017 Boston Marriott Copley Place Hotel Boston, MA United States See map: Google Maps AATS Centennial Saturday, April 29, 2017 to Wednesday, May 3, 2017 Boston Hynes Convention Center Boston, MA United States See map: Google Maps EuroGUCH 2017 Meeting - The Annual Meeting of the ESC Working Group Friday, May 5, 2017 The Olympic Museum Quai d'Ouchy 1 Lausanne 1006 Switzerland See map: map.search.ch, Google Maps Southwest Valve Summit 2017 Friday, May 5, 2017 to Sunday, May 7, 2017 JW Marriott San Antonio Hill Country Resort and Spa San Antonio, TX United States See map: Google Maps World Heart Congress Monday, May 22, 2017 to Wednesday, May 24, 2017 Hyatt Regency Osaka Osaka Japan See map: Google Maps Massachusetts General Hospital Postgraduate Course in General Thoracic Surgery Thursday, May 25, 2017 to Friday, May 26, 2017 Royal Sonesta Hotel Cambridge, MA United States See map: Google Maps

25th European Conference on General Thoracic Surgery Sunday, May 28, 2017 to Wednesday, May 31, 2017 Congress Messe Innsbruck Austria See map: Google Maps Toronto Update on Lung Transplantation and Artificial Lung Support Thursday, June 1, 2017 MaRS Discovery District - 101 College Street Toronto, ON Canada See map: Google Maps Thoracic Refresher Friday, June 2, 2017 to Saturday, June 3, 2017 MaRS Discovery District - 101 College Street Toronto, ON Canada See map: Google Maps Fundamentals in Cardiac Surgery: Part II Monday, June 5, 2017 to Friday, June 9, 2017 EACTS House Windsor United Kingdom See map: Google Maps Thoracic Surgery: Part II Monday, June 12, 2017 to Wednesday, June 14, 2017 EACTS House Windsor United Kingdom See map: Google Maps 17th European Congress on Extracorporeal Circulation Technology Wednesday, June 14, 2017 to Saturday, June 17, 2017 Palais des Congres, Parc Chanot Marseille France See map: Google Maps Ventricular Assist Device Co-ordinators Training Course Thursday, June 15, 2017 to Saturday, June 17, 2017 Deutsches Herzzentrum Berlin (German Heart Institute Berlin) Berlin Germany See map: Google Maps 18th Annual Cardiologists Conference Monday, June 19, 2017 to Wednesday, June 21, 2017 Hotel Novotel Marne la Vallée Noisy le Grand Paris France See map: Google Maps

https://www.ctsnet.org/events/12th-vienna-interdisciplinary-symposium-aortic-repair-visar

https://www.ctsnet.org/events/12th-vienna-interdisciplinary-symposium-aortic-repair-visar

https://www.ctsnet.org/events/aats-mitral-conclave

https://www.ctsnet.org/events/aats-innovation-summit

https://www.ctsnet.org/events/aats-centennial

https://www.ctsnet.org/events/euroguch-2017-meeting-annual-meeting-esc-working-group

https://www.ctsnet.org/events/euroguch-2017-meeting-annual-meeting-esc-working-group

http://map.search.ch/1006-Lausanne/Quai%20d%27Ouchy%201

https://www.ctsnet.org/events/southwest-valve-summit-2017

https://www.ctsnet.org/events/world-heart-congress

https://www.ctsnet.org/events/massachusetts-general-hospital-postgraduate-course-general-thoracic-surgery-1

https://www.ctsnet.org/events/massachusetts-general-hospital-postgraduate-course-general-thoracic-surgery-1

https://www.ctsnet.org/events/25th-european-conference-general-thoracic-surgery


https://www.ctsnet.org/events/toronto-update-lung-transplantation-and-artificial-lung-support

https://www.ctsnet.org/events/toronto-update-lung-transplantation-and-artificial-lung-support

https://www.ctsnet.org/events/thoracic-refresher

https://www.ctsnet.org/events/fundamentals-cardiac-surgery-part-ii-1

https://www.ctsnet.org/events/thoracic-surgery-part-ii-2

https://www.ctsnet.org/events/17th-european-congress-extracorporeal-circulation-technology

https://www.ctsnet.org/events/17th-european-congress-extracorporeal-circulation-technology

http://maps.google.fr/?q=Palais+des+Congres%2C+Parc+Chanot%2C+Marseille%2C+%2C+fr

https://www.ctsnet.org/events/ventricular-assist-device-co-ordinators-training-course-1

https://www.ctsnet.org/events/ventricular-assist-device-co-ordinators-training-course-1

https://www.ctsnet.org/events/18th-annual-cardiologists-conference

http://maps.google.fr/?q=Hotel+Novotel+Marne+la+Vall%C3%A9e+Noisy+le+Grand%2C+Paris%2C+%2C+fr

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Magna Græcia AORtic Interventional Project® (MAORI) 5th Symposium Complex Diseases of Thoracic and Thoraco-Abdominal Aorta Tuesday, June 20, 2017 to Wednesday, June 21, 2017 University Campus “Salvatore Venuta” Italy Building H, Auditorium Room B, level 2 Catanzaro Italy See map: Google Maps ASAIO 63rd Annual Conference Wednesday, June 21, 2017 to Saturday, June 24, 2017 Hyatt Regency Chicago Chicago, IL United States See map: Google Maps WTSA 43rd Annual Meeting Wednesday, June 21, 2017 to Saturday, June 24, 2017 The Broadmoor Colorado Springs, CO United States See map: Google Maps The New Orleans Conference - Las Vegas Edition Wednesday, June 28, 2017 to Saturday, July 1, 2017 The Four Seasons Resort Las Vegas, NV United States See map: Google Maps Basic Science Friday, June 30, 2017 to Saturday, July 1, 2017 EACTS House Windsor United Arab Emirates See map: Google Maps International Conference on Vascular Biology & Medicine Monday, July 24, 2017 to Tuesday, July 25, 2017 Doubletree by Hilton Chicago United States See map: Google Maps 4th International Conference on Brain Disorder and Brain Injury Monday, August 14, 2017 to Wednesday, August 16, 2017 Holiday Inn Toronto International Airport 970 Dixon Road Rexdale Toronto, ON M9W 1J9 Canada See map: Google Maps International Coronary Congress Friday, August 18, 2017 to Sunday, August 20, 2017

New York Marriott Marquis, Times Square New York, NY United States See map: Google Maps 27th Annual Congress of the World Society of Cardiovascular &Thoracic Surgeons Friday, September 1, 2017 to Sunday, September 3, 2017 The Palace Of Independence Astana Kazakhstan See map: Google Maps 2nd International Conference on Hypertension & Healthcare Monday, September 11, 2017 to Wednesday, September 13, 2017 Hyatt Place Amsterdam Airport Rijnlanderweg 800 Hoofddorp 2132 NN Amsterdam Netherlands See map: Google Maps Annual Conference on Heart Diseases Monday, September 18, 2017 to Tuesday, September 19, 2017 Holiday Inn Toronto International Airport 970 Dixon Road Toronto, ON M9W 1J9 Canada See map: Google Maps International Conference and Expo on Heart Surgery Thursday, September 21, 2017 to Friday, September 22, 2017 Hilton San Antonio Airport Hotel 611 NW Loop 410 San Antonio, TX United States See map: Google Maps 13th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion Thursday, September 28, 2017 to Saturday, September 30, 2017 Ospedale Pediatrico Bambino Gesù / Pontificia Università Urbaniana Via Urbano VIII Rome 16 - 00165 Italy See map: Google Maps 37th Annual Cardiothoracic Surgery Symposium Thursday, September 28, 2017 to Sunday, October 1, 2017

https://www.ctsnet.org/events/magna-gr%C3%A6cia-aortic-interventional-project%C2%AE-maori-5th-symposium-complex-diseases-thoracic-and



https://www.ctsnet.org/events/asaio-63rd-annual-conference

https://www.ctsnet.org/events/wtsa-43rd-annual-meeting

https://www.ctsnet.org/events/new-orleans-conference-las-vegas-edition

https://www.ctsnet.org/events/basic-science

https://www.ctsnet.org/events/international-conference-vascular-biology-medicine

https://www.ctsnet.org/events/international-conference-vascular-biology-medicine

https://www.ctsnet.org/events/4th-international-conference-brain-disorder-and-brain-injury

https://www.ctsnet.org/events/4th-international-conference-brain-disorder-and-brain-injury

https://www.ctsnet.org/events/international-coronary-congress

https://www.ctsnet.org/events/27th-annual-congress-world-society-cardiovascular-thoracic-surgeons

https://www.ctsnet.org/events/27th-annual-congress-world-society-cardiovascular-thoracic-surgeons

https://www.ctsnet.org/events/2nd-international-conference-hypertension-healthcare

https://www.ctsnet.org/events/2nd-international-conference-hypertension-healthcare

https://www.ctsnet.org/events/annual-conference-heart-diseases

https://www.ctsnet.org/events/international-conference-and-expo-heart-surgery

https://www.ctsnet.org/events/international-conference-and-expo-heart-surgery

https://www.ctsnet.org/events/13th-international-conference-pediatric-mechanical-circulatory-support-systems-and-pediatric



https://www.ctsnet.org/events/37th-annual-cardiothoracic-surgery-symposium

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Westin San Diego Gaslamp Quarter San Diego, CA United States See map: Google Maps Cardiothoracic Trauma Webinar (Repeat) Sunday, October 1, 2017 The Royal College of Surgeons of Edinburgh (RCSEd) Edinburgh United Kingdom See map: Google Maps 20th European Cardiology Conference Monday, October 16, 2017 to Wednesday, October 18, 2017 Budapest Hungary See map: Google Maps Fundamentals in Cardiac Surgery: Part III Monday, October 23, 2017 to Friday, October 27, 2017 EACTS House Windsor United Kingdom See map: Google Maps 27th Annual Congress of the Association of Thoracic and Cardiovascular Surgeons of Asia (ATCSA) Thursday, November 16, 2017 to Sunday, November 19, 2017

Melbourne Convention and Exhibition Centre Melbourne, VIC Australia See map: Google Maps Thoracic Surgery: Part III Monday, December 4, 2017 to Wednesday, December 6, 2017 EACTS House Windsor United Kingdom See map: Google Maps 14th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion Thursday, May 3, 2018 to Saturday, May 5, 2018 Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago, IL United States See map: Google Maps 26th European Conference on General Thoracic Surgery Saturday, May 26, 2018 to Wednesday, May 30, 2018 Cankarjev dom Culture and Congress Centre Ljubljana Slovenia See map: Google Maps

https://www.ctsnet.org/events/cardiothoracic-trauma-webinar-repeat

https://www.ctsnet.org/events/20th-european-cardiology-conference

https://www.ctsnet.org/events/fundamentals-cardiac-surgery-part-iii

https://www.ctsnet.org/events/27th-annual-congress-association-thoracic-and-cardiovascular-surgeons-asia-atcsa

https://www.ctsnet.org/events/27th-annual-congress-association-thoracic-and-cardiovascular-surgeons-asia-atcsa

https://www.ctsnet.org/events/thoracic-surgery-part-iii






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SUBSCRIPTION ORDER FORM

Please enter my subscription to The Iranian Heart Journal for 500 000 Rials for one year

(Four quarterly issues) beginning (Year)

ADDRESS: Please type or print clearly:

Name:

Address:

Zip Code: City:

PAYMENT

Check enclosed Cheek or money order must be made to:

Iranian Heart Association

Account no: 6166/1, Mellat Bank, Rajaie Cardiovascular,

Medical and Research Center Branch, Tehran, Iran.

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SUBSCRIPTION ORDER FORM

Please enter my subscription to The Iranian Heart Journal for $ 50 us. for one year

(Four quarterly issues) beginning (Year)

ADDRESS: Please type or print clearly:

Name:

Address:

Zip Code: City:

PAYMENT

Check enclosed Cheek or money order must be made to:


Account no: 116AC252899, Mellat Bank, Mirdamad Branch

Tehran, Iran, Branch code 6507/8

P.O.Box: 15745-1341

Bill me

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تهران :گيرنده مجلة قلب ايران

11731-1431صندوق پستي

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

To:


P.O.Box: 15745-1341

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issn: 1735-7306 - journal.iha.org.irjournal.iha.org.ir/files/journal/issue_9.pdf · abdi s....

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