Hossein Sadeghi

Prognosis after stroke followed by surgical closure of patent foramen ovale A prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound

Background: The risk of stroke and the long-term prognosis of recurrent strokes in young patients with patent foramen ovale (PFO) are not well known. For this reason, the treatment of these patients remains empirical. An alternative treatment to prolonged antithrombotic therapy may be surgical closure of the PFO. Methods: Thirty patients (20 men and 10 women) with stroke and PFO were prospectively selected among 138 patients with stroke and PFO for a study of surgical closure of PFO at our center. Eligible patients were <60 years old, had negative results of a systematic search for another cause of stroke (first criterion), and met two of the four following criteria: (1) recurrent clinical cerebrovascular events or multiple ischemic lesions on brain MR, (2) PFO associated with an atrial septal aneurysm, (3) >50 microbubbles counted in the left atrium on contrast transesophageal echocardiography (TEE), and (4) Valsalva maneuver or cough preceding the stroke. Patients selected in this manner for surgery were considered to be a subgroup with a higher risk of stroke recurrence. Results: All patients had a direct suture of PFO while under cardiopulmonary bypass without recorded early or delayed significant complication. All patients underwent a new brain MRI and TEE simultaneous with transcranial Doppler ultrasonography after contrast injection at 8 +/- 3 months after surgery. After a mean follow-up of 2 years without antithrombotic treatment, no recurrent cerebrovascular event (stroke or transient ischemic attack [TIA]) and no new lesion on MRI had developed. Postoperative contrast TEE and transcranial Doppler ultrasonography showed that two patients had residual interatrial right-to-left shunting, although much smaller than before surgery, associated with single versus double continuous suture. Conclusions: Our study of 30 selected stroke patients with surgical suture of PFO showed a stroke recurrence rate of 0% and no significant complication. Residual right-to-left shunting may be avoided by double continuous suture of the PFO. In the absence of controlled studies to guide individual therapeutic decisions, our findings show that PFO closure can be done safely and may be considered to avoid recurrence in selected patients with long life expectancy and presumed paradoxic embolism. NEUROLOGY 1996;47: 1162-1166

Intravascular stenting for stenosis of aortocoronary venous bypass grafts

To test the ability of endoluminal stents to prevent saphenous vein graft restenosis after balloon angioplasty, 13 patients with angina and previous coronary bypass surgery underwent implantation of one or more stents into 14 stenosed grafts. Implantation was technically successful in all cases and there were no major in-hospital complications. During a median follow-up interval of 7 months (range 2 to 26), 10 patients (77%) underwent follow-up angiography. Seven patients remained asymptomatic or in improved condition without further intervention; three patients had further angioplasty with stent implantation for a new stenosis in the same graft. Two patients (20%) developed within-stent restenosis. There was one death from progressive congestive heart failure 7 months after implantation. No patient had a myocardial infarction or needed surgical revascularization during the follow-up period. In selected cases, stent implantation appears to be a promising new technique that may decrease the incidence of restenosis after balloon angioplasty in venous bypass grafts. The rate of complications is low. Further experience and longer follow-up will be needed before definite recommendations can be made about its use.

Incidence of deep and superficial sternal infection after open heart surgery. A ten years retrospective study from 1981 to 1991.

Between January 1981 and December 1991, 4137 adult patients underwent various cardiac procedures via a median sternotomy under cardiopulmonary bypass. The overall infection rate was 1.33%, including superficial wound infections (SWI) (1.18%) and deep sternal infection (DSI) (0.145%). Pericardial and retrosternal suction drains with a vent allowed a better drainage of blood and serosities and probably contributed to our low DSI rate. Eleven factors predisposing to infection were evaluated by Fishers exact test. Only the operative urgency (P = 0.006), reexploration for bleeding (P = 0.00001) and preoperative renal failure (P = 0.0005) were statistically significant. Twenty of our infected patients had no risk factors for infection. When the risk factors described in the literature were applied to our infected patients, only one had no risk factor.

Complications after Single versus Dual Chamber Pacemaker Implantation

To compare the complication rate in patients having a dual chamber versus a single chamber pacing system, 337 consecutive procedures performed during a 3‐year period were analyzed prospectively. Two hundred fifty‐eight patients (77%) received a VVI pacemaker and 75 (23%) a DDD unit. Thirteen VVI (5%) and 4 DDD (5.3%) needed reintervention. Lead displacement with reoperation was required for three ventricular leads (1%) and one atrial lead (1.3%). Infection occurred in two WI units (0.77%) and one DDD (1.33%) unit. Muscular stimulation was noticed among three DDD (4%) and nine VVI systems (3.5%). Urgent reprogramming was needed for 23 VVI (9%) and six DDD units (8%). There was no increase in complications with dual chamber pacing compared to single chamber systems.

Improvement of left ventricular function after percutaneous transluminal coronary angioplasty

Cardiac function and left ventricular dynamics were measured in seven consecutive patients 1 day before and 6 months after percutaneous transluminal balloon angioplasty of subtotal proximal stenosis of the left anterior descending coronary artery. Before angioplasty all patients had obvious left ventricular dysfunction during exercise and to a smaller degree during isoproterenol infusion; the condition of all patients was greatly improved 6 months after angioplasty. After angioplasty, left ventricular end-diastolic pressure was normal at rest and decreased from a mean (+/- standard error of the mean) of 33.8 +/- 1.6 to 19.2 +/- 0.5 mm Hg on exercise. Left ventricular ejection fraction, measured by a gated blood pooling technique with technetium-99m, improved on exercise from 46 +/- 5.0 percent to 69 +/- 1.0 percent. Cardiac output and stroke volume index increased significantly with exercise after angioplasty. The peak negative rate of pressure reduction in the left ventricle (dP/dt/min), an index of left ventricular relaxation, was highly abnormal on exercise before (2,307 +/- 260 mm Hg/s) and increased to the normal range (3,154 +/- 200 mm Hg/s) after angioplasty. The improvement in left ventricular function after transluminal angioplasty in these cases of proximal left anterior descending coronary arterial stenosis is extremely encouraging.

Cardiac perforation after surgical repair of pectus excavatum.

Five days after surgical repair of pectus excavatum, this 7-year-old boy had a right-sided Kirschner wire protruding beneath the skin. The wire was repositioned blindly. Severe congestive heart failure developed. Surgical exploration showed a pierced right atrium, a torn septal leaflet of the tricuspid valve and noncoronary aortic cusp, and a large traumatic ventricular septal defect. The outcome and the indications and possible complications of surgery are discussed.

Semicontinuous Suture Technique for All Prosthetic Valve Insertions: The “Hoist” Technique

The semicontinuous suture technique as an alternative method in valve replacement is described. This specific technique is applicable for both adults and children requiring valvular prosthetic operations. This method combines advantages of the continuous and interrupted suture techniques.

Coronary stenting for coronary artery narrowing in a heart transplant recipient

Transplant atherosclerotic coronary disease remains the leading cause of death in heart transplant recipients. We report the first case of coronary stent implantation in a heart graft for epicardial focal stenosis. Due to the lower rate of restenosis after stenting in the native coronary artery, we suggest that coronary stenting be considered an acceptable, first intention therapeutic option instead of angioplasty alone whenever possible.

Percutaneous Transluminal Coronary Stenting: A New Approach to Unresolved Problems in Coronary Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) has been established as a safe and effective procedure for improving blood flow in narrowed atherosclerotic arteries. The stenoses recur, however, in a certain percentage of initially successful cases. Also, PTCA may resolve in abrupt closure of the artery due to intimai dissection and formation of intimai flaps or thrombosis. The purpose of an intravascular endoprosthesis (stent) is to restore and maintain blood flow by nonsurgical implantation via a catheter after transluminal angioplasty.