Tehran University Medical Journal

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A role of adenosine in pathogenesis of syndrome X has recently been postulated. Previous studies suggest that aminophylline (An adenosine receptor blocker) improves exercise tolerance in this disorder. Present study was performed to examine the efficacy of Theophylline in syndrome X and to determine the incidence of cardiovascular risk factors and clinical, ECG and angiographic findings in these patients. 31 patients were studied. The first 16 patients received Theophylline. Other 15 cases received placebo. Exercise tolerance test was repeated after 1-2 weeks. Patients who received Theophylline had increase in rate-pressure product at peak exercise and decrease in symptoms during exercise, but stage of st depression, global and peak st depression, exercise tolerance and persistence of st depression more than 3 minutes in recovery and symptoms of patients in general were not significant different. Theophylline has a favorable effect on exercise, reduces chest pain and rate-pressure product at peak exercise in patients with syndrome X, but not on other variables of exercise test.

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Complications of Coronary artery disease remain the most common cause of morbidity and mortality after vascular surgical procedures. Goldman risk factor analysis has been suggested as peri-operative noninvasive screening method to detect significant coronary artery disease in emergent vascular procedures.
Methods and Materials: In this study, the accuracy of the Goldman scale was assessed with regard to the development of cardiac complications such as asymptomatic ischemic change in ECG, arrhythmia, myocardial infarction and cardiac death. We studied 100 patients that were required emergent vascular procedures from 2000-2001. Data about perioperative complications were extracted and analyzed using SPSS computer program.
Results: Our study indicated there is not statistical correlation between cardiac death, infarction, arrythmia, ECG change, age, sex and cardiac class.
Conclusion: We concluded that Goldman scale could not be regarded as a screening method to predict peri-operative cardiac complications in emergent vascular procedures.

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Background: During general anesthesia in patients with mediastinal mass compression effect on the heart, great intra thoracic vessels, or tracheal tree can lead to decrease venous return, cardiovascular collapse or tracheal obstruction. These complications may be worsened after induction of general anesthesia or prescribing muscle relaxants.
Case report: A twenty one years old female with huge anterior mediastinal mass was a candidate for right sided thoracotomy. Compression effect on the adjacent structures has been reported in chest CT scan and in echocardiography. Awake oro-tracheal intubation was performed in sitting position. Then patient positioned to left lateral decubitus for thoracotomy During surgery asystole occured. We changed the position to remove compression effect on the heart and great vessels. Fortunately these maneuvers changed asystole to sinus rhythm.
Conclusion: Decreased thoracic muscular tone and removed spontaneous ventilation after muscle relaxant may threaten patient’s life. Change of patient’s position can remove the compression effect.

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Background: Cardiac connective tissue dysplasia syndrome consists of mitral valve prolapse (MVP), anomalously located chordae tendinae of the left ventricle, or a combination of the two. MVP is marked by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. The nonclassic form of MVP carries a low risk of complications. Patients with severe classic MVP can suffer from mitral regurgitation (MR), infective endocarditis, and, infrequently, sudden death from cardiac arrest. Anomalously located left ventricular chordae tendinae are fibrous or fibromuscular bands that stretch across the left ventricle from the septum to the free wall. They have been associated with murmurs and arrhythmias. The purpose of this study is to assess the performance, as measured by the physical working capacity (PWC170) and maximal oxygen consumption (VO2 max), in athletes with cardiac connective tissue dysplasia syndrome.
Methods: Of the 183 male athletes studied, 158 had cardiac connective tissue dysplasia syndrome and 25 were normal, healthy controls. Their mean age was 16.23 (± 5.48) years and mean training time was 5.2 (±- 4.6) years. Athletes with cardiac connective tissue dysplasia syndrome were divided to four groups. Group 1 consisted of those with MVP Group 2 had patients with an additional cord in left ventricle Group 3 was made up of athletes with a combination of MVP and additional cord Group 4 contained athletes with a combination of MVP and MR. All sportsmen were studied by echocardiograph, veloergometer, and those with arrhythmias were studied and recorded using a Holter monitor.
Results: The most common form of this syndrome in our study groups was MVP. The PWC170and VO2 max among the athletes with the combination of MVP+MR (Group 4) was lower than that of athletes in other groups (P<0.05). The most common arrhythmia among the athletes with anomalously located left ventricular chordae, Group 2, was Wolf-Parkinson-White (WPW) syndrome and early repolarization syndrome. The PWC170 and VO2 max in athletes with WPW syndrome, was lower than the other athletes who did not have WPW syndrome (P<0.05).
Conclusion: The lowest PWC170 and VO2 max were in those athletes with a progressive abnormality. However, the PWC170 and VO2 max among athletes with anomalously located left ventricular chordae was normal. Therefore, among athletes with a combination of anomalously located left ventricular chordae and disruption of rhythm, the PWC170 and VO2 max are lower than normal.

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Background: The Fontan operation is the definitive operation for palliation of complex congenital heart disease with single –ventricle physiology. The use of the extra cardiac conduit has recently been gaining popularity. The purpose of this study was to compare the outcomes of extra cardiac conduit Fontan procedure (off-pump technique) and that of traditional technique (lateral tunnel technique) in which cardiopulmonary bypass is routinely used.
Methods: Forty one patients in different age groups underwent extra cardiac conduit Fontan procedure between April 2001 and December 2004. Data were collected from ICU sheets, files and during follow up visits. Under general anesthesia and through median sternotomy, using two temporary decompressing shunts, superior vena cava implanted on right pulmonary artery and a conduit interposed between transected inferior vena cava and main pulmonary artery. Fenestration was done in almost all patients and previous shunts were closed if there were any.
Results: Of our patients, 13 were female and 28 were male. Mean age of the patients was 11.1 years (SD=7.8).In 24.4% of cases Fontan procedure was done as the first palliative surgery and in 75.6% of them there was previous history of palliative procedures. In 6 patients (14.6%) we were constrained to use cardiopulmonary bypass which was predictable or necessary in 50% of cases. There was no reoperation due to post operative bleeding. Two cases suffered from prolonged plural effusion. Our in-hospital mortality was 9.8%. During 2-24 months follow up, we found two cases who were in NYHA functional class II and one case in functional class I.
Conclusion: Extra cardiac conduit Fontan procedure could be used in a safe way. The results of this study were comparable and even in some cases better than that of the traditional technique.

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Background: Several randomized controlled trials have demonstrated the safety and efficacy of drug eluting stents (DES) in selected groups of patients with less complicated diabetes. We conducted this study to determine how an unselected group of diabetic patients in Iran fare following DES implantation.

Methods: Data were collected on 147 consecutive diabetic patients who underwent percutaneous coronary intervention (PCI) with the implantation of at least one DES at the Tehran Heart Center from June 2003 to September 2005. Clinical follow-up was performed by timely scheduled visits at one, four and nine months following DES implantation. Nine months of follow-up was completed for 94.5% of the patients. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which include cardiac death, myocardial infarction and target vessel revascularization (TVR). In-hospital complications were the secondary endpoint.

Results: A total of 158 coronary artery lesions were treated with DES in 147 diabetic patients (mean age = 56.4±8.92 years, 57.1% were men). During the nine-month follow-up, MACE occurred in 3.4% of patients, with a myocardial infarction rate of 1.4% and TVR rate of 1.4%. Considering one patient who underwent TVR due to acute stent thrombosis following angioplasty (during hospitalization) the total number of TVR reached 3 (2%). Only one patient (0.7%) died of cardiac death, which occurred after the procedure and before discharge. In-hospital complications occurred in six patients (4.1%) five patients suffered from myocardial infarction.

Conclusions: PCI with DES seems to be safe and effective in diabetic patients. However, more studies with larger study populations and longer follow-up are required to confirm this issue.

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Background: Cardiac herniation is a fatal post pneumonectomy complication. We report the signs, clinical findings, diagnosis and management of a patient with post pneumonectomy cardiac herniation.

Case report: A 34-year-old man with lung cancer underwent left pneumonectomy with partial pericardiectomy in the right lateral decubitus position. At the end of the surgery, cardiovascular collapse, severe bradycardia, desaturation and elevated airway pressure occurred just after repositioning the patient to the supine position. This patient survived as we returned him to the right lateral decubitus position and avoided the use of positive pressure ventilation.

Conclusions: Attention to the acute complications of pneumonectomy, diagnosis and rapid therapeutic interventions is essential in post pneumonectomy care.

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Background: Radiation to some parts of the heart is unavoidable in the therapeutic course of primary tumors in many kinds of cancer, including breast cancer. The aim of this study was to assess the frequency of acute and subacute cardiac complications following radiotherapy in patients with left breast cancer.
Methods: In this study, we enrolled 53 patients with left breast cancer who underwent mastectomy or lumpectomy between September 2005 and September 2006 in Imam Khomeini Hospital Complex, and subsequently underwent chemotherapy with anthracyclines (<450mg/m²) and Endoxan plus taxane/fFluorouracil followed by radiotherapy. In all patients, electrocardiography and echocardiography were performed before initiation of radiotherapy, immediately after radiotherapy and again three and six months later to check for radiotherapy-induced cardiac complications such as pericardial effusion, valvular lesions, left ventricular dysfunction, conduction system disturbances and other variables.
Results: Thirty-nine patients completed the follow-up period. Among these, 10 (25.6%) patients experienced cardiac complications following radiotherapy. Among these, mild pericardial effusion in seven (53.85%) patients, mild mitral regurgitation in three cases (23.08%) and Right Bundle Branch Block (RBBB) in two cases (15.38%) were the most common complications. We found no correlation between cardiac complication and tumor dose, dose fraction and type of chemotherapy protocol. We noted no cases of new or more serious complications, such as cardiomyopathies or coronary artery disease, nor any changes in ejection fraction by the end of the follow-up period.

Conclusion: In patients with left breast cancer, acute and subacute cardiac complications following radiotherapy are not serious and have no clinical significance. Further studies are needed for more assessments in this area.

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Background: The postmortem diagnosis of early myocardial infarction is a perplexing affair in forensic pathology. The routine evaluations of autopsied hearts including macroscopic examination and study of H&E stained sections are often not contributory. Some other methods like electron microscopy need sophisticated equipments which are not available in all pathology laboratories.

Methods: In an attempt to find a more reliable and less labor- intensive method, we have studied the diagnostic value of cardiac troponin- T by an optimized immunohistochemical method on 67 autopsied hearts in Legal Medicine Organization of Iran. The cases were divided into three groups: the positive group composed of cases with the definite diagnosis of myocardial infarction (MI) as the cause of death the non-cardiac death group and finally the suspicious group which consisted of cases with high probability of early myocardial infarction, however without definite evidence of MI on the routine histopathologic studies. In stained sections, the degree of troponin T depletion was scored.

Results: With our proposed cut off, this test showed positive results in 19 out of 22 cases in MI group (86.4%), none of the 17 cases of non-cardiac death (100% specificity), and 15 out of 28 cases of suspicious group (53.6%).

Conclusions: This relatively easy method may increase the sensitivity of routine histopathologic methods in postmortem detection of early myocardial infarction. Additionally, this method does not require a particular preparation and can be done very easily on the archival paraffin blocks available in pathology departments whenever further evaluation is deemed necessary by the pathologist.

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Background: The usage of pericardium of patient himself, for support of anastomosis lines may carry benefits in patients undergoing aortic valve replacement with pulmonary autograft (Ross). The aim of the present study was to compare the short term results of aortic valve replacement with pulmonary autograft with routine and offered methods.

Methods: In a non-randomized clinical trial, 64 patients who referred to cardiac surgery ward of Imam Khomeini hospital Tehran Iran from December 2002 to December 2006 for aortic valve replacement with pulmonary autograft with two different methods. In the first two years of this study all of the patients were operated with routine procedure (group A, n=28) and during the next two years, all of them were operated with authors' offered method in which the patient`s pericardium was used for support of anastomosis lines (group B, n=36). Some of clinical parameters and outcome were compared between two groups.

Results: There were no significant differences between mean of age, sex, pathology, preoperative and postoperative EF in two groups. In group B, the mean pump time was significantly lower than group A (144.09±26 vs. 179.64±25 min). The mean Cross-clamp time was significantly lower in group B (118.5±22 vs. 136.93±19 min) Need for blood transfusion in ICU was significantly lower in group B (35.71% vs. 68.57%). Mean ICU Stay and Postoperative Hospital Stay were significantly lower in group B (1.3±0.3 vs. 1.9±0.7 and 5.2±0.9 vs. 5.9±1.5 days respectively). Overall mortality was four death (6.25%) which was not significant between two groups.

Conclusions: The usage of patient's pericardium for support of anastomosis lines in patients undergoing aortic root replacement with pulmonary autograft carry advantages to routine procedure and its utilization is advocated in other centers.

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Normal 0 false false false EN-GB X-NONE AR-SA MicrosoftInternetExplorer4 Background: Acardiac twin is a rare complication affecting monozygotic twins and is related to the twin reversed atrial perfusion sequence (TRAP). The TRAP sequence involves a pump twin perfusing a recipient twin through vascular anastomosis. Here, we report two cases with different presentations of acardiac twin.
Case report: The first acardiac twin was composed of a healthy fetus and a fetus with proximal of trunk, pelvic and lower limbs without head, neck and arms (acardia acephalus- classic form). The pregnancy was followed with ultrasonography and pregnancy terminated at 29 weeks, because there was abnormal doppler of ductus venosus and non-reassuring NST in pump twin. The second acardiac twin first time was diagnosed at a rotine ultrasonography at 26 weeks gestation as a healthy fetus and an acardia fetus with a hypoplastic lower limb and intestine like organ (amorphic mass). The pregnancy following, normal infant was born with a sac with some loops of the intestine at term. Each two cases were diagnosed at 26 week and each was delivered healthy pump twin.
Conclusion: Acardiac twin has different presentation and here we presented two end of acardia twin presentation with different management and outcome.

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Background: Coronary Artery Disease (CAD) is one of the leading causes of mortality and morbidity all over the world. One of the most important predictors of outcome of patients with coronary aterey disease is the site of stenosis i.e. Proximal versus nonproximal stenosis. This study designed to evaluate the relationship between CAD risk factors and site of stenosis. Methods: In this case- control study in the patients undergone coronary angiography (CAG) in Imam Khomeini Hospital, Tehran, Iran a total of 125 CAD patients with proximal lesion in CAG enrolled the study as case group and equal sex and age matched number of patients with non proximal lesion selected as control group. Two groups were compared based on presence or absence of DM, hypertension, hyper cholestrolemia, hypertriglyceridemia and cigarette smoking. Results: Relative frequency of DM was 33.6% and 10.4% in case and control group respectively (p< 0.0001). Relative frequency in two groups were 33.6 vs 28.8% For HTN (p= 0.41), 30.4% vs 29.6% for hyper cholestrolemia (p= 0.89), 19.2% vs 16.8% for hypertriglyceridemia (p= 0.062) and 28.8 vs 39.2 for C/S (p= 0.08). Multivessle disease was significantly more prevalent in diabetics compared with non diabetic patients 89.1% vs 61% (p< 0.0001), no relationship was seen with HTN (p= 0.41), Hyper cholest- rolemia (p= 0.052) hypertriglyceridemia (p= 0.38) and cigarette smoking (p= 0.375). Conclusion: Proximal involvement of coronary arteries and multivessle disease in CAD patients is related to the history of DM but not to the history of hypertension, hypercholestrolemia, hypertriglyceridemia and cigarette smoking.

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Background: One of the most important components of coronary artery bypass graft surgery is need for blood transfusion that increases morbidity and mortality. The aim of this study was to evaluate the factors affecting the need for blood transfusion during off pump coronary artery bypass (OPCAB) surgery.
Methods: In this descriptive case control study 923 patients who had undergone OPCAB at Afshar Hospital in Yazd, Iran, from July 2008 to January 2010 were evaluated. The data was gathered from their records and was analyzed.
Results: 54% of male and 79% of female patient need blood transfusion. Mean age in patients needed transfusion was 61.58±11.11 years and in other group was 60.27±10.98 years of the patients that needed transfusion (p= 0.08). 563 (61%) of the patients needed transfusion with the average of two units. The need for blood transfusion was higher in female gender (p< 0.0001), low hematocrit (p< 0.0001), diabetes (p< 0.001), hypertension (p< 0.025) and multiple grafts (p< 0.027). There were no significant differences in preoperative hemostasis tests, affection to hyperlipidemia, CVA or renal failure, antiplatelet drug administration and the application of left internal mammary artery between the transfusion and non transfusion groups.
Conclusion: In this study preoperative hematocrit was most important risk factor in transfusion in patients that underwent OPCAB. Female gender, preoperative low hematocrit, multiple grafts, diabetes and hypertension increased the rate of blood transfusion. According to the high prevalence of blood transfusion in OPCAB, considering factors that affect the transfusion rate is essential.

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Background: Cardiac resynchronization therapy (CRT) has proved as an efficient treatment in patients with end stage Heart failure. Previous studies showed the beneficial long term effects of CRT on the severity of mitral regurgitation (MR). The aim of this study was to evaluate acute effects of CRT on severity of MR.

Methods: This study was a double blind randomized trial performed from 1387 to 1388 in Imam Khomeini Hospital. Echocardiographic parameters including severity of MR were measured before and after CRT implantation with different echocardiographic methods.

Results: Patients had a significant improvement in severity of MR (14% Vs. 11% P<0/05), in increasing ejection fraction (18/04 Vs. 24/42 P<0/05) and in decreasing end systolic diameters (6/14 Vs. 5/98 P<0/05) and end diastolic diameters (7 Vs. 6/8 P<0/05) after CRT implantation. The reduction of MR was significantly correlated with the improvement of ejection fraction (P=0.07).

Conclusion: The mechanism of decreasing severity of MR is not yet truly understood and may be different in acute and chronic phases. Correction of left ventricular dyssynchrony might influence the improvement of MR severity. Also, synchronization of papillary muscle and increased transmitral pressure with more forceful mitral valve closure, decreases regurgitation fraction and volumes is proposed for these beneficial effects. If posterior papillary muscle is involved in dyssynchrony, the acute reduction of MR following CRT is expected but if the dyssynchrony is mainly at the lateral parts of left ventricle MR might be improved in longer durations.

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Background: It is generally accepted that the selective adenosine triphosphate-dependent potassium channel openers (KATP openers) have a dramatic role in the treatment of some cardiovascular disorders. The aim of this study was to investigate the effects of diazoxide, a potent ATP-related potassium channel opener, on spontaneously beating isolated rat atria to achieve more accurate approaches to treat cardiovascular diseases, such as atrial related disorders including atrial arrhythmias.
Methods: After induction of anesthesia, we exsected the heart and isolated the atria of 48 male Wistar rats. Later, we recorded the beating and contractile force of the atria by a physiograph. Subsequently, we studied the effects of diazoxide (2 to 100 µg/mL) on beating and contractile force of the isolated atria 5, 10, 15 and 20 minutes after applying the drug onto the atria.
Results: Diazoxide administration (2 to 100 µg/mL) showed a significant decrease (7% to 49% depending on concentration) in atrial beatings (P≤0.001) and in contractile force (1.5% to 67% depending on concentration), (P≤0.001). The effects began several minutes after applying the drug onto the tissues.
Conclusion: This study revealed that diazoxide has a direct concentration-dependent effect on cardiac performance and leads to reduction in beating rates and contractile force of the heart. This effect seems to be related to the activation of mitochondrial or sarcolemmal KATP channels. Since the inhibitory action of diazoxide on the heart was very remarkable and prompt, this agent may also exhibit antiarrhythmic properties.

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Background: The Trigemino-cardiac reflex (TCR) has been studied as a phenomenon including bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve.
Case presentation: We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine (0.5mg/IV) and did not happen again.
Conclusion: The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

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Background: Primary cardiac tumors are rare tumors which should be operated urgently. In this study, cardiac myxoma have been evaluated from diagnosis until dis-charge in a 10 years period and then results including presenting symptoms, approach to the patients were compared with similar study in this center a decade ago. Methods: Patients who underwent operation for myxoma from year 2003 until 2013 in the Shahid Modarres Hospital were included in this study. Results: Eighteen patients included in the study, 11 female and seven male. Patients’ ages were in the range of 13 to 76 years (mean 53 years). Mean time from diagnosis to operation was 5.8 days and mean time from surgery to discharge was 8.6±6.1 days. Most common presenting symptoms were first clinical presentation in four patients. In all patents echocardiography was the main diagnostic modality. In addition to trans thoracic echocardiography (TTE), in five patients TEE was used and in 13 patients coronary angiography was used to rule out concomitant coronary artery disease. 94.4% of all tumors (17 cases) were primary cardiac tumors and only one tumor (5.6%) was recurrent. In 16 patients (88.9%) tumor were found in the Left Atrium (L.A) and in one case, tumor was found in both atria and in another case, tumor was in the ventricle. After tumor excision, atrial septum was repaired primarily in seven cases (38.9%) and with pericardial patch in 9 cases. One patient underwent concomitant coronary artery bypass graft (CABG) and another patient underwent concomitant pulmonary valve repair. 14 patients (77.8%) discharged from hospital without any post operative complication. Heart block occurred in one patient and cerebral emboli with secondary cerebrovascular accident (CVA) developed in two patients. One patient died (5.6%). Conclusion: Comparing results from two similar studies in two consecutive decades revealed that mean time from diagnosis to operation obviously was reduced but ad-vances in diagnostic modalities were unable to change clinical presentation or reduce age of tumor diagnosis or complications or size.

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Background: The primary manifestation of cardiac tumors in embryonic period is a very rare condition. Cardiac rhabdomyomas most frequently arise in the ventricular myocardium, they may also occur in the atria and the epicardial surface. In spite of its benign nature, the critical location of the tumor inside the heart can lead to lethal arrhythmias and chamber obstruction. Multiple rhabdomyomas are strongly associated with tuberous sclerosis which is associated with mental retardation and epilepsy of variable severity. Ultrasonography as a part of routine prenatal screening, is the best method for the diagnosis of cardiac rhabdomyomas. In the review of articles published in Iran, fetal cardiac rhabdomyoma was not reported.

Case presentation: We report a case of cardiac rhabdomyoma on a 24-year-old gravid 1, referred to Day Medical Imaging Center for routine evaluation of fetal abnormalities at 31 weeks of her gestational age. Ultrasonographic examination displayed a homogenous echogenic mass (13×9mm), originating from the left ventricle of the fetal heart. It was a normal pregnancy without any specific complications. Other organs of the fetus were found normal and no cardiac abnormalities were appeared. No Pericardial fluid effusion was found. The parents did not have consanguineous marriage. They did not also have any specific disease such as tuberous sclerosis.

Conclusion: The clinical features of cardiac rhabdomyomas vary widely, depending on the location, size, and number of tumors in the heart. Although cardiac rhabdomyoma is a benign tumor in many affected fetuses, an early prenatal diagnosis of the tumor is of great significance in making efficient planning and providing adequate follow up visits of the patients and the complications such as, heart failure and outlet obstruction of cardiac chambers.

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Background: We retrospectively compared the clinical outcome of post-cardiac surgery tracheal extubation between patients extubated with a lower than normal pH and patients extubated according to our routine institutional protocol. Our main goal was to clarify that strict adherence to the current criteria is dispensable. Methods: In this retrospective cohort study, we recruited 256 patients who met our study criteria and divided them into the exposed group (n= 95) and the control group (n= 161). The inclusion criteria consisted of coronary artery bypass grafting alone and age> 18 years. The exclusion criteria comprised the use of corticosteroids in the preceding 2 weeks, Serum creatinine (SCr)> 2 mg/dL, uncontrolled diabetes, liver dysfunction, Glasgow coma scale <13, and acetazolamide and sodium bicarbonate use. The arterial blood gas (ABG) characteristics before and 6 hours after extubation, extubation failure rate, length of stay in the in ICU, length of stay in the hospital and mortality were compared between the two groups. Results: In the control group, the males outnumbered the females and the ejection fraction was higher relative to that in the exposure group (P= 0.01 and P= 0.02, respectively). There were more patients with chronic obstructive pulmonary disease in the exposure group (P< 0.005) and also the euroSCORE was higher (P< 0.002). There were no significant differences between the groups regarding the ABG values at the time of ICU admission. Significantly higher levels of FiO2 and PaCO2 (P< 0.001 for both) as well as lower HCO3 and pH (P< 0.001 for both) were observed in the exposure group immediately before extubation. Following extubation, there was a significant increase in pH and a significant reduction in FiO2 need in the exposure group (P< 0.001 for both). The extubation failure rate, length of stay in the in ICU, length of stay in the hospital, and mortality rate were not different between the 2 groups.

Conclusion: The patients with a lower than normal pH, tracheal extubated at the discretion of the ICU anesthesiologist did not have a clinical outcome worse than that of the patients extubated in accordance with our routine institutional protocol.

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Background: We assessed different systolic cardiac indices to describe left and right ventricular dysfunction in cirrhotic patients before liver transplantation. Methods: In this case-control study, eighty-one consecutive individuals with the confirmed hepatic cirrhosis and candidate for liver transplantation in the Imam Khomeini Hospital between March 2008 and March 2010 were selected. Thirty-two age and gender cross-matched healthy volunteers were also selected as the control group. A detailed two-dimensional and Doppler echocardiography was obtained in all patients and controls performed by the same operator on the day of admission. Results: Dimensions of both left and right atriums as well as left ventricular end-diastolic volume and basal right ventricular dimension in the cirrhotic group were significantly higher than control group. Left ventricular end-systolic dimensions as well as aortic annulus diameter were not different between the two study groups. Left ventricular outflow tract velocity time integral, isovolumic pre-ejection time, isovolumic relaxation time, stroke volume, left ventricular ejection fraction, IVCT+IVRT+ET, systolic velocity of tricuspid annulus, systolic velocity of basal segment of RV free wall, systolic velocity of basal segment of septal wall, peak strain of septal margin (base), peak strain of septal margin (midpoint), peak strain of lateral margin (midpoint), strain rate of septal margin (base), strain rate of septal margin (midpoint), strain rate of lateral margin (base), strain rate of lateral margin (midpoint), Tei index (left and right ventricles), systolic time interval and tricuspid annular plane systolic excursion were higher in cirrhotic group, significantly, (P< 0.05). Left ventricular ejection time and systolic velocity of mid segment of lateral wall were lower in cirrhotic group, significantly, (P< 0.05).

Conclusion: In this study, the effects of liver on heart were volume overload, hyperdynamic state and systolic dysfunction in cirrhotic patients. These effects were due to chamber enlargement and we cannot use the most of cardiac indices for evaluation systolic function in cirrhotic patients. So, we suggest that systolic time interval and Tei index are useful indices in evaluation of systolic function in cirrhotic patients.