Journal of Tehran University Heart Center

Zohair Yousef Al-halees, MD , FRCSC, FACS 

King Faisal Heart Institute, Saudi Arabia 

Yadolah Dodge, PhD 

University of Neuchâtel, Switzerland 

Ali Dodge-Khatami, MD, PhD 

University of Hamburg-Eppendorf School of Medicne, Germany 

Iradj Gandjbakhch, MD 

Hopital Pitie, France 

Omer Isik, MD 

Yeditepe University, School of Medicine, Turkey 

Sami S. Kabbani, MD 

Damascus University Cardiovascular Surgical Center, Syria 

Kayvan Kamalvand, MD, FRCP, FACC 

William Harvey Hospital, United Kingdom 

Jean Marco, MD, FESC 

Centre Cardio- Thoracique de Monaco, France 

Ali Massumi, MD 

Texas Heart Institute, U. S. A 

Carlos-A. Mestres, MD 

University of Barcelona, Spain 

Hossien Ahmadi, MD 

Tehran University of Medical Sciences 

Shahin Akhondzadeh, PhD 


Mohammad Alidoosti, MD 


Mohammad Ali Boroumand, MD 


Ahmad Reza Dehpour, PhD 


Abbasali Karimi, MD 


Seyed Ebrahim Kassaian, MD 


Davood Kazemi Saleh, MD 

Baghiatallah University of Medical Sciences 

Majid Maleki, MD 

Iran University of Medical Sciences 

Mehrab Marzban, MD 


Mansor Moghadam, MD 


Sina Moradmand Badie, MD 


Seyed Mahmood Mirhoseini, MD, DSc, FACC, FAES 


THE 

JOURNAL OF TEHRAN 

UNIVERSITY HEART 

CENTER 

Editor-in-Chief 

ABBASALI KARIMI, MD 

PROFESSOR OF CARDIAC SURGERY 

TEHRAN UNIVERSITY OF MEDICAL SCIENCES 

Managing Editor 

SEYED HESAMEDDIN ABBASI, MD 

TEHRAN HEART CENTER 

TEHRAN UNIVERSITY OF MEDICAL SCIENCES 

International Editors 

Editorial Board 

Fred Morady, MD 

University of Michigan, U. S. A 

Mohammed T. Numan, MD 

University of Texas, U. S. A 

Ahmand S. Omran, MD, FACC, FASE 

King Abdulaziz Cardiac Center, Saudi Arabia 

Fausto J. Pinto, MD, PhD, FESC, FACC, FASA, FSCAI, 

FASE 

Lisbon University, Portugal 

Mehrdad Rezaee, MD, PhD 

Stanford University, School of Medicine, U. S. A 

Gregory S. Thomas, MD, MPH, FACC, FACP, FASNC 

University of California, U. S. A 

Lee Samuel Wann, MD 

Wisconsin Heart Hospital, U. S. A 

Hein J. Wellens, MD 

Cardiovascular Research Institute, Maastricht, The Netherlands 

Douglas P. Zipes, MD 

Indiana University, School of medicine, U. S. A 

Seyed Rasoul Mirsharifi, MD 


Ahmad Mohebi, MD 


Mohammad-Hasan Namazi 

Shaheed beheshti University of Medical Sciences 

Ebrahim Nematipour, MD 


Rezayat Parvizi, MD 

Tabriz University of Medical Sciences 

Masoud Pezeshkian 


Hassan Radmehr, MD 


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Nizal Sarraf –Zadegan, MD 

Isfahan University of Medical Sciences 

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Tehran University of Medical Sciences

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Saeed Davoodi, MD 


Iraj Firoozi, MD 


Seyed Khalil Foroozannia, MD 

Shaheed Sadoghi University of Medical Sciences 

Armen Gasparyan MD, PhD 

Armenia 

Ali Ghaemian, MD 

Mazandaran University of Medical Sciences 

Namvar Ghasemi Movahedi, MD 


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Ali Mohammad Haji Zeinali, MD 


Mohammad Jafar Hashemi, MD 


Mahmood Sheikh Fathollahi 

Pedram Amouzadeh 

Fatemeh Esmaeili Darabi 

Seyed Kianoosh Hoseini 


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Rostock University Medical Faculty 

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Content 

Volume: 6 Number: 2 Spring 2011 

The Journal of Tehran University Heart Center 

Review Article 

Cardiovascular Effects of Saffron: An Evidence-Based Review 

Maryam Kamalipour, Shahin Akhondzadeh …………….................................................................................................................................................... 59 

Original Articles 

Demographics and Angiographic Findings in Patients under 35 Years of Age with Acute ST Elevation Myocardial 

Infarction 

Seyed Kianoosh Hosseini, Abbas Soleimani, Mojtaba Salarifar, Hamidreza Pourhoseini, Ebrahim Nematipoor, Seyed Hesameddin Abbasi, Ali Abbasi ...... 62 

Signal-Averaged Electrocardiography in Patients with Advanced Heart Failure: A Better Indicator of Left 

Ventricular Enlargement Compared with Conventional Electrocardiography 

Mohammad Alasti, Majid Haghjoo, Abolfath Alizadeh, Mohammad Hossein Nikoo, Hamid Reza Bonakdar, Bita Omidvar .......................................... 68 

Carotid Artery Wall Motion Estimation from Consecutive Ultrasonic Images: Comparison of Block Matching and 

Maximum Gradient Algorithms 

Effat Soleimani, Manijhe Mokhtari-Dizaji, Hajir Saberi .................................................................................................................................................... 72 

Transcatheter Closure of Atrial Septal Defect with Amplatzer Septal Occluder in Adults: Immediate, Short, and 

Intermediate-Term Results 

Mostafa Behjati, Mansour Rafiei, Mohammad Hossein Soltani, Mahmoud Emami, Majid Dehghani ................................................................ 79 

Case Reports 

Incidental Finding of Cor Triatriatum Sinistrum in a Middle-Aged Man Candidated for Coronary Bypass Grafting 

(with Three-D Imaging) 

Afsoon Fazlinezhad, Farveh Vakilian, Asadollah Mirzaei, Azadeh Fallah Rastegar ……................................................................................................... 85 

Segmented Coronary Artery Aneurysms and Kawasaki Disease 

Mohammad Yoosef Aarabi Moghadam, Hojat Mortazaeian, Mehdi Ghaderian, Hamid Reza Ghaemi ……..…................................................................ 89 

Traumatic Left Anterior Descending Coronary Artery-Right Ventricle Fistula: A Case Report 

Mohammad Ali Sheikhi, Mehdi Asgari, Mehdi Dehghani Firouzabadi, Mohammad Reza Zeraati, Alireza Rezaee...……….............................……..… 92 

Letter to the Editor 

Percutaneous Revascularization of Patients with History of Coronary Artery Bypass Grafting 

Seyed Kianoosh Hoseini, Fatemeh Behboudi ………………………………………………..……………….......................................……....….....…… 95 

The Journal of Tehran University Heart Center



Cardiovascular Effects of Saffron: An Evidence-Based 

Review 

Maryam Kamalipour, MSc, Shahin Akhondzadeh, PhD, FBPharmacolS * 

Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran. 

Received 15 January 2011; Accepted 28 March 2011 

Abstract 

Herbal medicine can be a valuable source of assistance for traditional medicine. There are a number of herbs that can be 

used in conjunction with modern medicine. Herbs can also be taken to aid recovery from serious diseases. Although one should 

never aim to treat diseases such as cardiovascular disease solely with herbal medicine, the value of herbs used in tandem with 

modern medicine cannot be ignored. Saffron has been reported to help lower cholesterol and keep cholesterol levels healthy. 

Animal studies have shown saffron to lower cholesterol by as much as 50%. Saffron has antioxidant properties; it is, therefore, 

helpful in maintaining healthy arteries and blood vessels. Saffron is also known to have anti-inflammatory properties, which 

are beneficial to cardiovascular health. The people of Mediterranean countries, where saffron use is common, have lower 

than normal incidence of heart diseases. From saffron's cholesterol lowering benefits to its anti inflammatory properties, 

saffron may be one of the best supplements for cardiac health. This paper reviews the studies regarding the beneficial effects 

of saffron in cardiovascular health. 

J Teh Univ Heart Ctr 2011;6(2):59-61 

This paper should be cited as: Kamalipour M, Akhondzadeh S. Cardiovascular Effects of Saffron: An Evidence-Based Review. J 

Teh Univ Heart Ctr 2011;6(2):59-61. 

Keywords: Anti-inflammatory agents, non-steriodal • Cardiovascular agents • Lipid regulating agents • Crocus sativus 

Introduction 

The role of alternative medicine in general and 

phytotherapy in various diseases in particular has been of 

extreme interest to various scientific and non-scientific 

communities throughout the world. Phytotherapy is broadly 

defined as the use of natural therapeutic agents derived from 

plants or crude herbal drugs. Herbal medicine has a long and 

respected history and holds a valuable place in the treatment 

of cardiovascular diseases as well as the vast majority of 

health problems. Utilizing the leaves, flowers, stems, berries, 

and roots of plants to both prevent and treat illness, herbal 

medicine not only helps to alleviate symptoms but also helps 

to treat the underlying problem, as well as strengthen the 

overall functioning of a particular organ or body system. 1, 2 

Cardiovascular diseases are now considered a major cause 

of mortality not only in the developed world but also in the 

developing countries. In the age of genomics, nanotechnology, 

and proteomics, cardiovascular diseases continue to remain 

a major challenge to therapeutically manage; and the search 

for a viable evidence-based alternative continues. 

Saffron (Crocis sativus) is a spice derived from the flower 

of the saffron crocus (Crocus sativus), a species of crocus in 

the family Iridaceae. The flower has three stigmas, which 

are the distal ends of the plant’s carpels. Together with its 

style, the stalk connecting the stigmas to the rest of the plant, 

* 

Corresponding Author: Shahin Akhondzadeh, Professor of Neuroscience, Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran 

University of Medical Sciences, South Kargar Street, Tehran, Iran. 13337. Tel: +98 21 88281866, Fax: +98 21 55419113. E-mail: s.akhond@neda.net. 

The Journal of Tehran University Heart Center 59


Shahin Akhondzadeh et al. 

these components are often dried and used in cooking as a 

seasoning and coloring agent. Saffron, which has for decades 

been the world’s most expensive spice by weight, is native to 

Iran; it was first cultivated in the Persian Empire. 2, 3 Saffron 

is characterized by a bitter taste and an iodoform- or haylike 

fragrance; these are caused by the chemicals picrocrocin 

and safranal. It also contains a carotenoid dye, crocin, which 

gives food a rich golden-yellow hue. These traits make 

saffron a much-sought ingredient in many foods worldwide. 

Saffron also has medicinal applications. 3, 4 

Saffron tastes bitter and contributes a luminous yelloworange 

coloring to foods. Because of the unusual taste and 

coloring it adds to foods, saffron is widely used in Persian, 

Arab, Central Asian, European, Indian, Moroccan, and 

Cornish cuisines. Confectionaries and liquors also often 

include saffron. Medicinally, saffron has a long history as part 

of traditional healing; modern medicine has also discovered 

saffron as having anticarcinogenic (cancer-suppressing), 

anti-mutagenic (mutation-preventing), immuno-modulating, 

and antioxidant-like properties. Saffron has also been 

used as a fabric dye, particularly in China and India, and 

in perfumery. 1, 2 Recent studies have shown the beneficial 

effects of saffron in depression, premenstrual syndrome 

(PMS), and Alzheimer’s Disease. 3-9 

Saffron and Heart Disease Protection 

Antioxidants in saffron tea can reduce the risk of 

cardiovascular diseases. The flavonoids, especially lycopene, 

found in saffron can provide added protection. A clinical trial 

at the Department of Medicine and Indigenous Drug Research 

Center showed positive effects of saffron on cardiovascular 

diseases. 10 The study involved 20 participants, including 

10 with heart diseases. According to the Indian Journal of 

Medical Sciences, all the participants showed improved 

health, but those with cardiovascular diseases showed more 

progress. In addition, saffron has been found to be the richest 

source of riboflavin. 1, 2 Due to the presence of crocetin, it 

indirectly helps to reduce cholesterol level in the blood 

and severity of atherosclerosis, thus reducing the chances 

of heart attacks. It may be one of the prime reasons that in 

Spain, where Saffron is consumed liberally, the incidence of 

cardiovascular diseases is quite low. The crocetin present in 

saffron is found to increase the yield of antibiotics. 11 Two 

compounds of safranal are supposed to increase antibacterial 

and antiviral physiological activity in the body. 12 

In 2005, Zheng et al. administered crocetin, the natural 

carotenoid antioxidant, to rabbits to determine its effect on 

the development of atherosclerosis. The authors randomly 

assigned New Zealand white rabbits to three different diets 

for eight weeks: a standard diet, a high lipid diet (HLD), 

or a high lipid + crocetin diet. The HLD group developed 

hypercholesterolemia and atherosclerosis, while the 

crocetin-supplemented group decreased the negative health 

effects of a high lipid diet. 13 The results did not show a 

significant difference in the plasma lipid levels (total, low 

density lipoprotein (LDL), and high density lipoprotein 

(HDL) cholesterol) between the HLD and crocetin groups 

but did show a significant decrease in the aorta cholesterol 

deposits, atheroma, foam cells, and atherosclerotic lesions 

in the crocetin-fed group. They suggested that nuclear factor 

kappa B (NF-κB) activation in the aortas is suppressed by 

antioxidants such as crocetin which in turn decreases the 

vascular cell adhesion molecule-1 (VCAM-1) expression. 13 

A 2006 study by Sheng and colleagues looked at 

an alternative mechanism for crocin’s atherosclerotic 

properties. 14 Crocin inhibited an increase in serum 

triglycerides, total-, LDL-, cholesterol compared to the 

control group as seen before; however, the results also 

showed a significant increase in the fecal excretion of fat 

and cholesterol in the crocin group (100 mg/kg/day). 14 

Further studies determined that crocin inhibited pancreatic 

and gastric lipase activity, although a potential mechanism 

was not offered. Since pancreatic lipase is responsible for fat 

absorption by hydrolyzing fat, the inhibition of pancreatic 

lipase activity resulted in low lipid absorption. With a lack 

of potential pancreatic lipase inhibitors available, crocin 

shows promise as a drug for treating hyperlipidemia. 14 

In conclusion, saffron helps reduce the risk of heart 

diseases by strengthening the blood circulatory system. Rich 

in minerals like thiamin and riboflavin, saffron promotes a 

healthy heart and prevents different cardiac problems. 

References 

1. Schmidt M, Betti G, Hensel A. Saffron in phytotherapy: 

pharmacology and clinical uses. Wien Med Wochenschr 

2007;157:315-319. 

2. Bathaie SZ, Mousavi SZ. New applications and mechanisms of 

action of saffron and its important ingredients. Crit Rev Food Sci 

Nutr 2010;50:761-786. 

3. Akhondzadeh S, Tahmacebi-Pour N, Noorbala AA, Amini H, Fallah- 

Pour H, Jamshidi AH, Khani M. Crocus sativus L. in the treatment 

of mild to moderate depression: a double-blind, randomized and 

placebo controlled trial. Phytother Res 2005;19:148-151. 

4. Noorbala AA, Akhondzadeh S, Tahmacebi-Pour N, Jamshidi AH. 

Hydroalcoholic extract of Crocus sativus L. versus fluoxetine 

in the treatment of mild to moderate depression: a double-blind, 

randomized pilot trial. J Ethnopharmacol 2005;97:281-284. 

5. Moshiri E, Basti AA, Noorbala AA, Jamshidi AH, Abbasi S, 

Akhondzadeh SH. Crocus sativus L. (petal) in the treatment of 

mild-to-moderate depression: a double-blind, randomized and 

placebo controlled trial. Phytomedicine 2006;13:607-611. 

6. Akhondzadeh Basti A, Moshiri E, Noorbala AA, Jamshidi AH, 

Abbasi SH, Akhondzadeh S. Comparison of petal of Crocus sativus 

L. and fluoxetine in the treatment of depressed outpatients: a pilot 

double-blind randomized trial. Prog Neuropsychopharmacol Biol 

Psychiatry 2007;31:439-442. 

7. Agha-Hosseini M, Kashani L, Aleyaseen A, Ghoreishi A, 

Rahmanpour H, Zarrinara AR, Akhondzadeh S. Crocus sativus L. 

(saffron) in the treatment of premenstrual syndrome: a double-blind, 

randomised and placebo controlled trial. BJOG 2008;115:515- 

519. 

60

Cardiovascular Effects of Saffron: An Evidence-Based Review 


8. Akhondzadeh S, Sabet MS, Harirchian MH, Togha M, 

Cheraghmakani H, Razeghi S, Hejazi SS, Yousefi MH, Alimardani 

R, Jamshidi A, Zare F, Moradi A. Saffron in the treatment of patients 

with mild to moderate Alzheimer’s disease: a 16-week, randomized 

and placebo-controlled trial. J Clin Pharm Ther 2010;35:581-588. 

9. Akhondzadeh S, Shafiee Sabet M, Harirchian MH, Togha M, 

Cheraghmakani H, Razeghi S, Hejazi SS, Yousefi MH, Alimardani 

R, Jamshidi A, Rezazadeh SA, Yousefi A, Zare F, Moradi A, 

Vossoughi A. A 22-week, multicenter, randomized, doubleblind 

controlled trial of Crocus sativus in the treatment of mildto-moderate 

Alzheimer’s disease. Psychopharmacology (Berl) 

2010;207:637-643. 

10. Verma SK, Bordia A. Antioxidant property of Saffron in man. 

Indian J Med Sci 1998;52:205-207. 

11. Basker D, Negbi M. The use of saffron. Econ Bot 1983;37:228- 

236. 

12. Zarghami NS, Heinz DE. Monoterpene aldehydes and isophorone 

337 related compounds of saffron. Phytochemistry 1971;10:2755- 

2761. 

13. Zheng S, Qian Z, Tang F, Sheng L. Suppression of vascular 

cell adhesion molecule-1 expression by crocetin contributes to 

attenuation of atherosclerosis in hypercholesterolemic rabbits. 

Biochem Pharmacol 2005;70:1192-1199. 

14. Sheng L, Qian Z, Zheng S, Xi L. Mechanism of hypolipidemic 

effect of crocin in rats: crocin inhibits pancreatic lipase. Eur J 

Pharmacol 2006;543:116-122. 

The Journal of Tehran University Heart Center61


Original Article 

Demographics and Angiographic Findings in Patients 

under 35 Years of Age with Acute ST Elevation Myocardial 

Infarction 

Seyed Kianoosh Hosseini, MD 1 , Abbas Soleimani, MD 1 , Mojtaba Salarifar, 

MD 1* , Hamidreza Pourhoseini, MD 1 , Ebrahim Nematipoor, MD 1 , Seyed 

Hesameddin Abbasi, MD 1, 2 , Ali Abbasi, MD 3 

1 

Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. 

2 

Family Health Research Center, Iranian Petroleum Industry Health Research Institute, Tehran, Iran. 

3 

University Medical Center Groningen, Groningen, the Netherlands. 

Received 23 September 2010; Accepted 18 January 2011 

Abstract 

Background: ST-elevation myocardial infarction (STEMI) is a major cause of cardiovascular mortality worldwide. 

There are differences between very young patients with STEMI and their older counterparts. This study investigates the 

demographics and clinical findings in very young patients with STEMI. 

Methods: Through a review of the angiography registry, 108 patients aged ≤ 35 years (Group I) were compared with 5544 

patients aged > 35 years (Group II) who underwent coronary angiography after STEMI. 

Results: Group I patients were more likely to be male (92.6%), smokers, and have a family history of cardiovascular 

diseases (34.6%). The prevalence of diabetes, dyslipidemia, and hypertension was higher in the old patients. Triglyceride 

and hemoglobin were significantly higher in Group I. Normal coronary angiogram was reported in 18.5% of the young 

patients, and in 2.1% of the older patients. The prevalence of single-vessel and multi-vessel coronary artery disease was 

similar in the two groups (34.3% vs. 35.2%). The younger subjects were more commonly candidates for medical treatment 

and percutaneous coronary intervention (PCI) (84.2%), while coronary artery bypass grafting (CABG) was considered for 

the 39.5% of their older counterparts. 

Conclusion: In the young adults with STEMI, male gender, smoking, family history, and high triglyceride level were more 

often observed. A considerable proportion of the young patients presented with multi-vessel coronary disease. PCI or medical 

treatment was the preferred treatment in the younger patients; in contrast to their older counterparts, in whom CABG was 

more commonly chosen for revascularization. 


This paper should be cited as: Hosseini SK, Soleimani A, Salarifar M, Pourhoseini H, Nematipoor E, Abbasi SH, Abbasi A. 

Demographics and Angiographic Findings in Patients under 35 Years of Age with Acute ST Elevation Myocardial Infarction. J Teh Univ 

Heart Ctr 2011;6(2):62-67. 

Keywords: Myocardial infarction • Young adult • Coronary angiography • Risk factors 

* 

Corresponding Author: Mojtaba Salarifar, Assistant Professor of Interventional Cardiology, Cardiology Department, Tehran Heart Center, North 

Kargar Street, Tehran, Iran. 1411713138. Tel: +98 21 88029257. Fax: +98 21 88029256. E-mail: salarifar@tehranheartcenter.org. 

62

Demographics and Angiographic Findings in Patients under 35 Years of ... 

Introduction 

ST-segment elevation myocardial infarction (STEMI) is 

one of the most common causes of emergency department 

admissions and cardiovascular mortalities and thus currently 

accounts for a high burden on health care services in the 

world. Although STEMI is an uncommon entity in young 

patients, it has always attracted special attention because 

of its unusual features and devastating effect on their more 

active lifestyle. 1-5 

In recent years, whereas the mean age of coronary artery 

disease (CAD) has decreased, its prevalence seems to have 

been on the increase. 4 A number of studies, including our 

previous report, have shown significant differences in the risk 

factor profile and coronary angiographic patterns between 

young and older patients with acute STEMI. 1-3, 6-8 Traditional 

risk factors of CAD are prevalent in young patients with 

acute STEMI but with a different pattern compared to their 

older counterparts; these differences may cause different 

treatment strategies and outcome among these patients. 3, 

5, 9 

There is evidence that a concentration of the novel risk 

factors of CAD such as LP (a) may be higher than normal in 

the offspring of patients with a history of premature MI. 10 

There is a dearth of available data on very young adults with 

STEMI, as a life-threatening cardiac emergency condition. 

In an attempt to characterize patients 35 years of age or 

younger suffering STEMI, we reviewed the Tehran Heart 

Center Angiography Registry (THCAR) and compared the 

demographics and clinical findings of these patients to those 

older than 35 years of age. 

Methods 

From all the patients admitted by cardiologists between 

January 2000 and March 2008 to the Angiography 

Department affiliated with the Academic Tehran Heart Center, 

we identified 5652 patients with a history of STEMI. The 

databank contains patients’ data collected by cardiologists and 

trained general practitioners, and the validity of all the data 

is checked by reabstracting 10% of the patients’ entries and 

by reentering 5% of the patients' records. The investigation 

was approved by the institutional Review Board, overseeing 

the participation of human subjects in research at Tehran 

University of Medical Sciences. This study conforms to the 

principles outlined in the Declaration of Helsinki. 

The validation of acute myocardial infarction (AMI) events 

was based on information on medical history, symptoms, 

electrocardiogram, and cardiac enzymes. STEMI was 

diagnosed when new or presumed new ST-segment elevation 

≥ 1 mm ( ≥ 2 mm in V 1 

to V 3 

) was seen in any location in two 

or more contiguous leads or new left bundle branch block 

was found on the index or qualifying electrocardiogram 

with ≥ 1 positive cardiac biochemical marker of necrosis 


(including CKMB-mass or quantitative cardiac troponin 

measurements). The cardiologist who performed the coronary 

angiography documented and recorded STEMI diagnosis 

in the datasheets. Coronary angiography was performed in 

almost all the patients as part of the pharmacoinvasive strategy 

or as the primary treatment option (primary percutaneous 

coronary intervention [PCI]) based on the American College 

of Cardiology/American Heart Association (ACC/AHA) 

Guidelines for the management of patients with STEMI. 11 To 

characterize the young patients, the patients were divided into 

2 subgroups of ≤ 35 years (Group I, n = 108) and those older 

than 35 years (Group II, n = 5544). The following data were 

included for analysis: demographic data (i.e. age and gender) 

and CAD risk factor profile, comprised of current cigarette 

smoking history (patient regularly smokes a tobacco product/ 

products one or more times per day or has smoked in the 30 

days prior to admission), hyperlipidemia (total cholesterol ≥ 

5.0, HDL-cholesterol ≤ 1.0 in men or ≤ 1.1 in women, and 

triglycerides ≥ 2.0 mmol/l), family history of CAD (firstdegree 

relatives before the age of 55 in men and 65 years in 

women), hypertension (systolic blood pressure ≥ 140 and/or 

diastolic ≥ 90 mmHg and/or on anti-hypertensive treatment), 

diabetes mellitus (symptoms of diabetes and plasma glucose 

concentration ≥ 200 mg/dl (11.1 mmol/l), or fasting blood 

sugar (FBS) ≥ 126 mg/dl (7.0mmol/l) or 2-hp ≥ 200 mg/dl 

(11.1 mmol/l)), and opium consumption. 12 

Clinical manifestations, left ventricular ejection fraction 

(LVEF), hematologic indices, coronary angiographic findings, 

and treatment strategy were reported. Selective coronary 

arteriography was performed using standard technique in 

all the patients. Significant CAD was defined as a diameter 

stenosis > 50% in each major epicardial artery. A narrowing 

of < 50% was considered mild CAD. Normal vessels were 

defined as the complete absence of any disease in the left 

main coronary artery (LMCA), left anterior descending 

(LAD), right coronary artery (RCA), and left circumflex 

(LCx) as well as in their main branches (diagonal, obtuse 

marginal, ramus intermedius, posterior descending artery, 

and posterolateral branch). Even mild luminal irregularities 

were regarded as evidence of atherosclerosis. 

The results were reported as mean ± standard deviation 

(SD) for the quantitative variables and percentages for the 

categorical variables. The groups were compared using the 

Student t-test for the continuous variables and the Chi-square 

test for the dichotomous variables. This study was done with 

the power of 90%. P values of 0.05 or less were considered 

statistically significant. All the statistical analyses were 

carried out via Statistical Package for Social Sciences version 

16 (SPSS, IL, Chicago Inc., USA). 

Results 

The demographic and historical characteristics of the study 



Seyed Kianoosh Hosseini et al. 

population are listed in Table 1. The mean patient age was 56.7 

± 10.8 (Range: 17-95) years. The male patients accounted 

for 79.8% of the total study population. The risk factors 

included smoking in 30.8% of the cases, hyperlipidemia in 

59.4%, diabetes in 27.4%, and hypertension in 40.8% with 

an average body mass index (BMI) of 27.6 ± 4.4 kg/m 2 in 

this population. A family history of CAD was reported in 

24.2% of the patients. Use of opium as a risk factor 12 was 

found in 16.6% of 3716 patients who had information of 

opium use in the registry. 

The frequencies of the atherosclerotic risk factors, 

demographic, and clinical characteristics of the patients 

≤ 35 and > 35 years old were compared. In Group I, the 

frequency of the male gender, current smoking, and a family 

history of CAD was significantly more common than that 

of Group II (p value < 0.001). The patients above 35 years 

were more likely to have diabetes mellitus (p value < 0.001), 

hypertension (p value < 0.001), and hyperlipidemia (p value = 

0.009). Although the mean total cholesterol and high density 

lipoprotein levels were similar between two groups, the older 

patients had significantly higher low density lipoprotein and 

FBS and lower triglyceride levels in comparison with Group 

I. There was no significant statistical difference in the BMI 

(27.7 ± 4.2 vs. 27.0 ± 4.1 in Group I vs. II, respectively; p 

value = 0.111) and opium use between the two groups. 

There were 5527 (107 from Group I and 5420 from Group 

II) patients with STEMI, in whom baseline hemoglobin data 

were available. According to the World Health Organization 

definition (hemoglobin < 13 g/dL and < 12 g/dL for the male 

and female, respectively), 15.7% of the patients (867 of 

5420) presented with anemia. The mean hemoglobin level 

of Group II was lower than that of Group I (14.2 ± 1.8 vs. 

14.5 ± 1.5 g/dL, p value < 0.001); the young patients were 

less likely to be anemic compared with Group II (8.4% vs. 

15.8%, p value = 0.037). There were 989 (18%) patients 

with elevated serum creatinine (> 1.4 mg/dl). Group II 

patients were more likely to have impaired renal function in 

comparison with Group I (18.1% vs. 9.4%, p value = 0.037). 

There was no significant difference in the LVEF measured 

by echocardiography or left ventriculography between the 

two groups (Table 2). 

Significant coronary artery lesions were found in 5356 

Table 1. Demographic and historical characteristics of the patients * 

≤ 35years (n=108) > 35 years (n=5544) p value 

Male gender 100 (92.6) 4412 (79.6)



Table 2. Investigation findings and treatment strategy of the patients * 

≤ 35 years (n=108) > 35 years (n=5544) p value 

Echocardiography LVEF (%) 46.3±10.4 44.5±11.5 0.134 

RWMA 64 (68.8) 3470 (69.2) 0.931 

Catheterization LVEF (%) 46.6±10.5 44.3±11.6 0.051 

Coronary artery dominancy 

Right 86 (79.6) 4627 (83.4) 0.343 

Left 12 (11.1) 587 (10.6) 

Codominant 10 (9.3) 330 (5.9) 

Normal coronary angiogram 20 (18.5) 116 (2.1)


Seyed Kianoosh Hosseini et al. 

patients, smokers, and those with a family history of CAD 

have the propensity to earlier acute coronary syndromes 

(ACSs). 16-18 In the Sozzi et al. study, 18 the men developed 

AMI approximately 10 times more frequently than did the 

women, and also smoking and a family history were heavily 

present among the young patients. Zimmerman et al. 1 showed 

that a family history of premature CAD was more common 

in the young men with MI. A family history of premature 

MI has been considered as an independent risk factor for the 

development of cardiovascular events, particularly in young 

patients. 19-22 

The role of positive family history of premature CAD 

will be completed by many reports about the role of genetic 

factors in the development of atherosclerosis and occurrence 

of STEMI in young patients. According to recent published 

studies, there may be polymorphisms in genes such as 

methylene tetrahydrofolatereductase, 23 Platelet receptors, 24 

and plasminogen activator inhibitor 1 (PAI1), 25 which 

predispose the patients to STEMI. In contrast, there is at least 

one report about the polymorphism in beta fibrinogen gene 

and its protective effect against the incidence of premature 

STEMI. 26 Whether or not such findings could have therapeutic 

impacts needs to be illuminated in the future. 

As was expected, there was a lower incidence of 

hypertension, dyslipidemia, and diabetes in our younger 

17, 27, 

patients, which is in agreement with previous studies. 

28 

It is related to the long-term role of these metabolic and 

endocrine disorders in the atherosclerosis process and ACS. 

However, it is deserving of note that our young patients had 

higher levels of serum triglyceride. These findings suggest 

that coronary disease may have different predisposing 

conditions in this population. Early lifestyle modifications 

and pharmacological interventions should take into account 

smoking, dyslipidemia, and body weight control. It should 

be noted that hypertension and diabetes were less frequent at 

the young age. A general notion has evolved that the intensity 

of preventive efforts should be adjusted to a patient’s risk for 

developing CAD. 

Our findings that a normal coronary angiogram was more 

frequent in the young patients and that they had a higher 

frequency of single-vessel disease as compared to the older 

patients are consistent with previous reports. 1, 3, 29 Our older 

patients were more commonly diagnosed as multi-vessel 

disease in the coronary angiogram. It seems that younger 

patients who present with STEMI have lower atherosclerotic 

burden but higher propensity to thrombus formation. 

Autopsy observations have shown that the occurrence of 

MI in young people with cardiovascular risk factors could 

be the expression of a premature and severe atherosclerotic 

process. 30 Not surprisingly, we observed that the young 

patients were less likely to have prior catheterization and 

to refer for CABG as their treatment strategy for coronary 

revascularization. 

The current analysis is strengthened by the diversity and 

size of the population studied; be that as it may, a number 

of limitations should be noted. Patients ≤ 35 years of age 

comprised just 1.9% of the total STEMI population in the 

angiography registry, but this analysis of 5652 patients of 

STEMI represents one of the largest studies to focus on 

patients after infarction. As this study population represented 

relatively high-risk patients with MI, we remain cautious 

in generalizing these results to a broader group of lowerrisk, 

post-MI patients. Furthermore, our patients had 

been followed prospectively through other registries (i.e. 

Angioplasty and CABG); nevertheless, the present study, 

being a single-center survey may have lost some data of the 

patients who were not admitted. Some long-term follow-up 

events, particularly death and stroke, were not determined in 

this study. Accordingly, the present analysis cannot claim to 

represent the findings for all patients early after MI. 

Conclusion 

In conclusion, we found that the male gender, 

smoking, family history of cardiovascular diseases, and 

hypertriglyceridemia were more prevalent in the STEMI 

patients ≤ 35 years, whereas the elderly patients were more 

likely to have dyslipidemia, hypertension, and diabetes. 

Medical treatment or PCI were the preferred therapeutic 

strategy recommended to the younger patients in contrast 

to their older counterparts, in whom CABG was more 

commonly recommended. Further studies about the impact 

of genetic factors in the development of STEMI in young 

patients are needed. 

Acknowledgment 

We extend our gratitude to Dr. Mahmood Sheikhfathollahi 

for his assistance in the statistical analysis. This study was 

approved and supported by Tehran University of Medical 

Sciences. 

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infarction in young adults: angiographic characterisation, risk 

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2. Colkesen AY, Acil T, Demircan S, Sezgin AT, Muderrisoglu H. 

Coronary lesion type, location, and characteristics of acute ST 

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3. Pineda J, Marín F, Roldán V, Valencia J, Marco P, Sogorb F. 

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4. Ghadimi H, Bishehsari F, Allameh F. Clinical characteristics, 

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of acute myocardial infarction patients: the first report from Iran. 

66


Coron Artery Dis 2006;17:585-591. 

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8. Hosseini SK, Soleimani A, Karimi AA, Sadeghian S, Darabian S, 

Abbasi SH, Ahmadi SH, Zoroufian A, Mahmoodian M, Abbasi 

A. Clinical features, management and in-hospital outcome of ST 

elevation myocardial infarction (STEMI) in young adults under 40 

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patients: an uncommon but growing entity. Int J Cardiol 

2010;144:131-132. 

10. Gaeta G, Cuomo S, Capozzi G, Foglia MC, Barra S, Madrid A, 

Stornaiuolo V, Trevisan M. Lipoprotein (a) levels are increased 

in healthy young subjects with parental history of premature 

myocardial infarction. Nutr Metab Cardiovasc Dis 2008;18:492- 

496. 

11. Kushner FG, Hand M, Smith SC, Jr, King SB, 3rd, Anderson JL, 

Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, 

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DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, 

Williams DO. 2009 focused updates: ACC/AHA guidelines for the 

management of patients with ST-elevation myocardial infarction 

(updating the 2004 guideline and 2007 focused update) and ACC/ 

AHA/SCAI guidelines on percutaneous coronary intervention 

(updating the 2005 guideline and 2007 focused update) a report of 

the American College of Cardiology Foundation/American Heart 

Association Task Force on Practice Guidelines. J Am Coll Cardiol 

2009;54:2205-2241. 

12. Sadeghian S, Darvish S, Davoodi G, Salarifar M, Mahmoodian 

M, Fallah N, Karimi AA. The association of opium with coronary 

artery disease. Eur J Cardiovasc Prev Rehabil 2007;14:715-717. 

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of beta-fibrinogen gene and the risk of premature myocardial 

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of angiographic findings, risk factors, and long term followup 

between young and old patients with a history of myocardial 

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follow-up of coronary artery disease presenting in young adults. J 

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Signal-Averaged Electrocardiography in Patients with 

Advanced Heart Failure: A Better Indicator of Left 

Ventricular Enlargement Compared with Conventional 

Electrocardiography 

Mohammad Alasti, MD 1* , Majid Haghjoo, MD 2 , Abolfath Alizadeh, MD 2 , 

Mohammad Hossein Nikoo, MD 3 , Hamid Reza Bonakdar, MD4, Bita Omidvar, 

MD 5 

1 

Imam Khomeini Hospital, Jundishapur University of Medical Sciences, Ahvaz, Iran. 

2 

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

3 

Kosar Hospital, Shiraz, Iran. 

4 

Heshmat Hospital, Gilan University of Medical Sciences, Rasht, Iran. 

5 

Golestan Hospital, Jundishapur University of Medical Sciences, Ahvaz, Iran. 

Abstract 

Received 11 August 2010; Accepted 12 January 2011 

Background: The signal-averaged electrocardiography is a noninvasive method to evaluate the presence of the potentials 

generated by tissues activated later than their usual timing in the cardiac cycle. The purpose of this study was to demonstrate 

the correlation between the filtered QRS duration obtained via the signal-averaged electrocardiography and left ventricular 

dimensions and volumes and then to compare it with the standard electrocardiography. 

Methods: We included patients with advanced systolic left ventricular dysfunction (ejection fraction ≤ 35%). All the patients 

underwent surface twelve-lead electrocardiography, signal-averaged electrocardiography, and echocardiography. 

Results: The study included 86 patients with a mean age of 54.66 ± 13.23 years. The mean left ventricular ejection fraction 

was 18.31 ± 5.49%; the mean QRS duration was 0.14 ± 0.02 sec; and 52% of the patients had left bundle branch block. The 

mean filtered QRS duration was 145.87 ± 24.89 ms. Our data showed a significant linear relation between the filtered QRS 

duration and left ventricular end-systolic volume, left ventricular end-diastolic volume, left ventricular end-systolic diameter, 

and left ventricular end-diastolic diameter; the correlation coefficient was, however, not good. There was no significant 

correlation between the QRS duration and left ventricular diameters and volumes. 

Conclusion: The filtered QRS duration has a better correlation with left ventricular dimensions and volumes than does the 

QRS duration in the standard electrocardiography. 


This paper should be cited as: Alasti M, Haghjoo M, Alizadeh A, Nikoo MH, Bonakdar HR, Omidvar B. Signal-Averaged Electrocardiography 

in Patients with Advanced Heart Failure: A Better Indicator of Left Ventricular Enlargement Compared with Conventional Electrocardiography. 

J Teh Univ Heart Ctr 2011;6(2):68-71. 

Keywords: Heart failure • Echocardiography • Electrocardiography • Heart ventricles 

* 

Corresponding Author: Mohammad Alasti, Assistant Professor of Cardiology, Jondishpour University of Medical Sciences, Imam Khomeini Hospital, 

Azadegan Avenue, Ahwaz, Iran. 6193673166. Tel: +98 611 4457205. Fax: +98 611 4457205. E-mail: alastip@gmail.com. 

68

Signal-Averaged Electrocardiography in Patients with Advanced Heart Failure: ... 


Introduction 

The high resolution electrocardiography (ECG) is 

designed for the body surface recording of the cardiac signals 

that are not visible on the standard ECG. Signal averaging is 

an approach to produce a high resolution electrocardiogram. 

In this type of electrocardiography, late potentials are 

generated by tissues activated later than their usual timing in 

the cardiac cycle. 1 We, therefore, designed an observational 

study aimed at evaluating the possible correlation between 

the data obtained by the signal-averaged electrocardiography 

(SAECG) and left ventricular (LV) dimensions and volumes 

and compare it with the standard ECG. 

Methods 

The patients included in the study were selected 

consecutively among those referred with a diagnosis of 

heart failure. The inclusion criteria were advanced systolic 

LV dysfunction (LV ejection fraction [LVEF] ≤ 35%) and 

underlying cause (idiopathic dilated cardiomyopathy or 

ischemic heart disease). All the patients signed written 

informed consent. We excluded patients with non-sinus 

rhythm, previous pacemaker implantation, a recent myocardial 

infarction (< 3 months), and severe aortic disease. All the 

patients underwent standard twelve-lead ECG, SAECG, and 

two-dimensional echocardiography. 

Imaging was done in the left lateral decubitus position, 

recording the parasternal and apical views (standard longaxis 

and two- and four-chamber images) with the aid of a 

commercially available system (Vingmed 7, General Electric, 

Milwaukee, WI, USA). A 3.5-MHz transducer was used. 

The LV volumes (end-systolic and end-diastolic) and LVEF 

were calculated from the conventional apical two- and fourchamber 

images utilizing the biplane Simpson technique. 

The QRS duration was measured on the surface ECG. The 

ECG was recorded at a speed of 25 mm/sec and a scale of 

10 mm/mV. The QRS duration was measured as the widest 

QRS complex in the precordial leads. QRS durations ≥ 0.12 

sec; no q-wave but slurred, broad R waves in leads I, aVL, 

and V 6 

; and rS or QS deflections in lead V 1 

were considered 

as the ECG features of left bundle branch block (LBBB). On 

the other hand, QRS durations ≥ 120 ms, broad and notched 

R waves in leads V 1 

and V 2 

, and deep S deflections in the 

left precordial leads and I were noted as the ECG features 

of right bundle branch block (RBBB). A prolonged QRS 

not associated with the typical features of bundle branch 

block was labeled as nonspecific intraventricular conduction 

delay. 

Filtered QRS durations (fQRS) were calculated using the 

SAECG (Hellige EK 56, Marquette, Freiburg, Germany) 

with noise level < 0.3 µV and high-pass filtering of 35 Hz. 

The key hardware elements of the system were an amplifier, 

a convertor for the digitalization of the signals, a signal 

processor, and a printer. In this system, a computer algorithm 

was utilized to identify the QRS onset and offset. Filtering 

was applied to reduce the residual noise and improve the 

identification of the low potentials. 

The continuous data were expressed as mean ± standard 

deviation values. Linear regression analysis was the chosen 

method for evaluating the association between the signalaveraged 

data and the echocardiographic indices. A p value 

< 0.05 was considered statistically significant. 

Results 

The study population consisted of 86 patients: 67 (77.9%) 

men and 19 (22.1%) women with a mean age of 54.66 ± 13.23 

years (range: 18-79). The underlying etiology of heart failure 

was ischemic in 60% of the patients. Seventy-two (83.8%) 

patients were in New York Heart Association (NYHA) class 

III. The baseline characteristics of the study population are 

summarized in Table 1. 

Table 1. Baseline characteristics of study population * 

Variable n=86 

Age (y) 54.66±13.23 

Male/Female 67 (77.9) / 19 (22.1) 

Etiology of heart failure 

Ischemic 52 (60) 

Idiopathic 34 (40) 

NYHA class 

NYHA class II 12 (14) 

NYHA class III 72 (83.8) 

NYHA class IV 2 (2.3) 

QRS morphology 

Left bundle branch block 45 (52) 

Right bundle branch block 6 (7) 

Nonspecific intraventricular conduction delay 35 (41) 

* 

Data are presented as mean±SD or n (%) 

All the patients had sinus rhythm on the ECG. The mean 

QRS duration was 0.14 ± 0.03 sec (range: 0.08-0.2 sec), and 

45 (52%) patients had LBBB morphology. The mean fQRS 

duration was 145.87 ± 24.89 ms (range: 86-200 ms). 

The mean LVEF was 18.31 ± 5.49% (range: 10-33%), 

and 15.3% of the patients had severe mitral regurgitation. 

Detailed echocardiographic characteristics of the patients are 

presented in Table 2. 

The multiple linear regression (stepwise method) 

demonstrated that while there was a significant correlation 

between the fQRS duration and LV end-systolic volume 

(r = 0.37, p value = 0.000) (Figure 1-A), LV end-systolic 

diameter (r = 0.24, p value = 0.031) (Figure 1-B), LV end- 



Mohammad Alasti et al. 

Figure 1. A-Correlation between the left ventricular end-systolic volume (LVESV, ml) and filtered QRS duration (fQRS, ms) (r = 0.37, p value = 0.000). 

B- Correlation between the left ventricular end-systolic diameter (LVESD, cm) and filtered QRS duration (fQRS, ms) (r = 0.24, p value = 0.031). 

C- Correlation between the left ventricular end-diastolic volume (LVEDV, ml) and filtered QRS duration (fQRS, ms) (r = 0.31, p value = 0.004). 

D- Correlation between left ventricular end-diastolic diameter (LVEDD, cm) and filtered QRS duration (fQRS, ms) (r = 0.23, p value = 0.039) 

diastolic volume (r = 0.31, p value = 0.004) (Figure 1-C), and 

LV end-diastolic diameter (r = 0.23, p value = 0.039) (Figure 

1-D), there was no significant correlation between the fQRS 

duration and LVEF. In addition, the relation between age, 

sex, and underlying disease and the parameters in the model 

was not significant. 

There was no statistically significant relation between the 

QRS duration and LV dimensions, volumes, and EF (Table 3). 

Discussion 

QRS prolongation ( > 120 ms) occurs in 14% to 47% 

of patients with heart failure and is a common finding in 

approximately 30%. LBBB occurs more commonly than 

does RBBB (25% to 36% vs. 4% to 6%). 2 The prolongation of 

Table 2. Echocardiographic characteristics of study population (n=86) * 

Left ventricular ejection fraction (%) 18.31±5.49 (10-33) 

Left ventricular end-systolic diameter (cm) 6.15±0.90 (4.1-8.9) 

Left ventricular end-systolic volume (ml) 163.76±58.34 (53-367) 

Left ventricular end-diastolic diameter (cm) 7.00±0.86 (5.1-9.4) 

Left ventricular end-diastolic volume (ml) 209.56±64.16 (72-430) 

* 

Data are presented as mean±SD (range) 

70

Signal-Averaged Electrocardiography in Patients with Advanced Heart Failure: ... 


Table 3. Correlation of QRS duration and left ventricular dimensions and volumes assessed by two-dimensional echocardiography 

Variable Correlation Coefficient P value 

Left ventricular end-systolic diameter 0.13 0.249 

Left ventricular end-systolic volume 0.17 0.113 

Left ventricular end-diastolic diameter 0.10 0.358 

Left ventricular end-diastolic volume 0.11 0.329 

Left ventricular ejection fraction 0.04 0.125 

QRS is a significant predictor for LV systolic dysfunction in 

patients with heart failure. One heart failure study indicated 

that the incidence of QRS prolongation increased from 

10% to 32% and 53% when patients moved from NYHA 

functional class I to class II and III, respectively. 2 

In patients with heart failure, an inverse correlation 

exists between QRS prolongation and LVEF. In a study, a 

stepwise increase was found in the prevalence of systolic 

LV dysfunction as the QRS complex duration increased 

progressively above 120 ms. 2 As was stated in previous 

studies, the baseline QRS duration has no correlation with 

intraventricular dyssynchrony and is not predictive for 

clinical and echocardiographic responses. 2, 3 

The SAECG is a noninvasive test for the risk stratification 

of sudden cardiac deaths, especially in the survivors 

of myocardial infarction. This technique results in the 

improvement of the signal-to-noise ratio, thus allowing 

analysis of signals that are too small to be detected by routine 

measurement. 4 

There are some studies showing a better correlation 

between the SAECG data and intraventricular 

dyssynchrony. 5, 6 Our data showed that the fQRS duration 

in the SAECG had a significant linear correlation with LV 

diameters and volumes (despite low correlation coefficients) 

and was a better indicator of LV enlargement than was the 

QRS duration in the standard twelve-lead ECG. Hence, 

the SAECG can be more informative than standard ECG 

in patients with heart failure and may be used more in the 

future. 

This study has some major limitations, first and foremost 

amongst which is its small size, which requires the evaluation 

of a larger group of patients to confirm its results. Another 

limitation is the heterogeneity of the study population 

insofar as patients with ischemic or idiopathic dilated 

cardiomyopathies and patients with intraventricular delay or 

narrow QRS were all included in this study. In addition, the 

fact that the study patients were selected from those referred 

to us certainly creates some selection bias. 

our findings warrants further investigation. 


This study was supported by Cardiovascular Research 

Center of Ahvaz Jundishapur University of Medical 

Sciences. 

References 

1. Berbari EJ. High resolution electrocardiography. In: Zipes DP, 

Jalife J. eds. Cardiac Electrophysiology: from Cell to Bedside. 5th 

ed. Philadelphia: WB Saunders; 2004. p. 793-802. 

2. Kashani A, Barold S. Significance of QRS complex duration in 

patients with heart failure. J Am Coll Cardiol 2005;46:2183-2192. 

3. Mollema SA, Bleeker GB, van der Wall EE, Schalij MJ, Bax 

JJ. Usefulness of QRS duration to predict response to cardiac 

resynchronization therapy in patients with end-stage heart failure. 

Am J Cardiol 2007;100:1665-1670. 

4. Turitto G, Abdula R, Benson D, El-sherif N. Signal averaged 

electrocardiogram. In: Gussak I, Antzelevitch C, eds. Electrical 

Diseases of the Heart. 1st ed. London: Springer; 2008. p. 353-355. 

5. Tahara T, Sogou T, Suezawa C, Matsubara H, Tada N, Tsushima 

S, Kitawaki T, Shinohata R, Kusachi S. Filtered QRS duration on 

signal-averaged electrocardiography correlates with ventricular 

dyssynchrony assessed by tissue Doppler imaging in patients with 

reduced ventricular ejection fraction. J Electrocardiol 2010;43:48- 

53. 

6. Andrikopoulos GK, Tzeis S, Kolb C, Sakellariou D, Avramides 

D, Alexopoulos EC, Triantafyllou K, Manolis AS. Correlation of 

mechanical dyssynchrony with QRS duration measured by signalaveraged 

electrocardiography. Ann Noninvasive Electro cardiol 

2009;14:234-241. 

Conclusions 

According to our data, the fQRS duration has a better 

correlation with LV dimensions and volumes than does the 

QRS duration in standard ECG. The clinical significance of 




Carotid Artery Wall Motion Estimation from Consecutive 

Ultrasonic Images: Comparison between Block-Matching 

and Maximum-Gradient Algorithms 

Effat Soleimani, MSc 1 , Manijhe Mokhtari Dizaji, PhD 1* , Hajir Saberi, MD 2 

1 

Tarbiat Modares University, Tehran, Iran. 

2 

Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. 

Received 09 November 2010; Accepted 17 February 2011 

Abstract 

Background: Radial movement of the arterial wall is a well-known indicator of the mechanical properties of arteries in 

arterial disease examinations. In the present study, two different motion estimation methods, based on the block-matching 

and maximum-gradient algorithms, were examined to extract the radial displacement of the carotid artery wall. 

Methods: Each program was separately implemented to the same axial consecutive ultrasound images of the carotid 

artery of 10 healthy men, and the radial displacement waveform of this artery was extracted during two cardiac cycles. The 

results of the two methods were compared using the linear regression and Bland-Altman statistical analyses. The maximum 

and mean displacements traced by the block-matching algorithm were compared with the same parameters traced by the 

maximum-gradient algorithm. The frame numbers in which the maximum displacement of the wall occurred were compared 

too. 

Results: There were no significant differences between the maximum and the mean displacements traced by the blockmatching 

algorithm and the same parameters traced by the maximum-gradient algorithm according to the pair t-test analysis 

(p value > 0.05). There was a significant correlation between the radial movement of the common carotid artery measured 

with the block-matching and maximum-gradient methods (with a correlation coefficient of 0.89 and p value < 0.05). The 

Bland-Altman analysis results confirmed a good agreement between the two methods in measuring the radial movement, 

with a mean difference and limits of agreement of 0.044 ± 0.038. The results showed that both methods found the maximum 

displacement occurring in the same frame. 

Conclusion: Both block-matching and maximum-gradient algorithms can be used to extract the radial displacement of the 

carotid artery wall and in addition, with respect to the pixel size as error, the same results can be obtained. 


This paper should be cited as: Soleimani E, Mokhtari Dizaji M, Saberi H. Carotid Artery Wall Motion Estimation from Consecutive 

Ultrasonic Images: Comparison between Block-Matching and Maximum-Gradient Algorithms. J Teh Univ Heart Ctr 2011;6(1):72-78. 

Keywords: Ultrasonography • Carotid arteries • Motion • Algorithms 

* 

Corresponding Author: Manijhe Mokhtari-Dizaji, Professor of Medical Physics, Department of Medical Physics, Tarbiat Modares University, Jalal 

Ale-Ahmad Ave, Tehran, Iran. 14115133. Tel: +98 21 82883893. Fax: +98 21 88006544. E-mail: mokhtarm@modares.ac.ir. 

72

Carotid Artery Wall Motion Estimation from Consecutive Ultrasonic Images: 

Introduction 

Sclerotic and ageing changes in the human cardiovascular 

system are well reflected by the status and structure of 

carotid arteries. The elastic properties of the carotid artery 

are affected by different physiological states and external 

stimuli. The carotid artery wall structure, thickness, and 

stiffness are good indicators for the estimation of the risk 

of stroke, myocardial infarction, and vascular disease. This 

artery is well accessible by ultrasonic investigation and also 

is the main vessel supplying blood to the brain; ultrasonic 

investigations of the carotid artery have, therefore, been the 

target of numerous attempts. 1, 2 

Arteries in the human body are constantly moving due to 

the mechanical stresses to which they are subjected. In fact, 

blood pressure, blood flow, and tethering to the surrounding 

tissue cause stresses on the arterial wall, resulting in its 

motion. Stresses can lead to strains in three directions which, 

in relation to a B-mode ultrasonic image, correspond to 

changes in the radius of the vessel, changes in the axial length, 

and movement out of the B-mode section. 3 This motion 

may be responsible for tissue rupture and cerebrovascular 

symptoms. 

The high resolution B-mode ultrasonic imaging of the 

carotid artery is widely used in the diagnosis of atherosclerosis 

as it allows non-invasive measurements of the intima-media 

thickness and lumen diameter and assessment of the degree 

of stenosis as well as of plaque morphology. In addition 

to this, temporal sequences of ultrasound images can be 

employed to estimate the movement of the carotid artery 

wall. 4, 5 It has been confirmed that B-mode ultrasonic images, 

in combination with appropriate image-processing methods, 

may be utilized to extract useful physiological indices of 

the carotid artery wall, including anatomical, texture, and 

elasticity features (Grava C, Gacsádi A, Gavriluţ I. Arterial 

elasticity maps obtained by using basic block-matching 

methods. IEEE 2009;151-154. & Stoitsis J, Golemati S, 

Koropouli V, Nikita KS. Simulating dynamic B-mode 

ultrasound image data of the common carotid artery. IEEE 

Workshop Imag Syst Tech 2008;144-148.). But because of 

the nature of ultrasound imaging, there are regions in the 

image with insufficient image data to guide fully automated 

methods. However, with minimal operator input, semiautomated 

methods work well and provide reproducible 

estimates of luminal and vessel dimensions under realistic 

conditions (Herrington DM, Johnson T, Santago P, Snyder 

WE. Semi-automated boundary detection for intravascular 

ultrasound. IEEE 1992;103-106.). 

Boundary-detection algorithms often have been applied 

just to measure the intima-media thickness and internal 

diameter of arteries. We assessed the diameter changes of 

the carotid artery from consecutive ultrasonic B-mode 

images using the maximum-gradient algorithm. 6 Since 


motion analysis results have a significant role in diagnostic 

interpretation and different motion analysis methods may 

result in different findings, a comparative study of the 

block-matching and maximum-gradient algorithms for the 

estimation of the carotid artery wall motion in the radial 

direction is presented. 

Methods 

In the present study, two different methods are employed 

for a quantitative analysis of the carotid artery wall motion in 

the radial direction. The first method is based on the blockmatching 

algorithm. 7, 8 In the block-matching algorithm, as 

long as the brightness intensity is assumed to be constant, 

given a block of pixels or reference block in the current 

frame, matching consists in finding the block in the next (or 

previous) frames that best matches the block in the reference 

frame. The method requires a good measure of match. In 

order to avoid the incorrect matches, the search for the bestmatched 

block is typically constrained to a searching window, 

the size of which has to be appropriately chosen because 

it may affect the motion analysis results. The information 

obtained from a single pixel is not discriminatory enough 

to ensure unique matches. This is why the supplementary 

assumption is made that all the neighbor pixels in a block 

have the same movement. Thus, instead of one pixel, a 

block of pixels centered in the current pixel is considered 

(the reference block). Another assumption for correlating the 

movement of echo patterns to the associated tissue motion 

is that motions are in plane and are small. The displacement 

vector is estimated by matching the information content 

of a measurement window with that of a corresponding 

measurement window within a search area, placed in the 

previous frame. 

In the block-matching motion estimation methods, the 

best match is found by maximizing a similarity measure. 9 

The maximization of appropriate correlation measures or 

coefficients can be also used in the block-matching methods. 10 

This algorithm allows the automatic motion tracking of one 

or more region(s) of interest [ROI(s)] on the vessel wall, in a 

9, 10 

sequence of ultrasound images. 

The second method is edge detection based, which is a 

combination of dynamic programming and maximum gradient. 

The dynamic programming algorithm is an optimization of 

the cost function by finding optimal polyline, corresponding 

to the artery boundary. Within a rectangular region close 

to the boundary searched for, local measurements of echo 

intensity, intensity gradient, and boundary continuity are 

extracted and included as weighted terms in a cost function. 

Each image point of the search region then gets a specific 

cost. The points are thereafter connected by lines forming 

a polyline, and the scanning of the image line by line in 



Effat Soleimani et al. 

horizontal direction is performed. The optimal polyline is 

the one that minimizes the cost function. The maximumgradient 

algorithm searches along a path perpendicular to 

the boundary and picks up the point of maximum intensity 

gradient. The reference points are placed in the middle of 

the artery. The points are subsequently connected by lines, 

and the scanning of the image line by line in the horizontal 

direction is performed. The gradient of each vertical line 

is calculated. The boundaries are searched for the local 

maximums of the image line’s gradient to the left and to the 

right from the predefined middle line. This algorithm has 

been previously validated by the manual method. 6 Since the 

dynamic programming algorithm has the highest accuracy 

and the maximum-gradient algorithm requires no training 

to perform measurements, 1, 4, 11 we combined them and 

designed new software in which the reference points were 

selected as the maximum-gradient algorithm and the points 

with maximum gradients were picked up. Afterward, the best 

candidates were those with the least cost function. The cost 

function was defined according to the dynamic programming 

algorithm. 

The ultrasonic examination of the right common carotid 

artery of 10 healthy men (aged 41 ± 2 years) with no history 

of cardiovascular disease, hypertension, or diabetes 2 was 

performed. All the subjects gave informed written consent 

for the examination. Before ultrasonography, the subjects 

rested for at least 10 minutes in the supine position until 

their heart rate and blood pressure reached a steady state. 

The common carotid artery of the subjects, 2-3 cm proximal 

to the bifurcation, was examined with a Sonoline Antares 

(Siemens, Germany) ultrasound system equipped with a 

5 - 13 MHz linear transducer. the audio video interleave 

(AVI) format of the consecutive images of the common 

carotid artery with a frame rate of 30 frames per second 

was transferred to a PC for post processing. Each recording 

contained two cardiac cycles, and the right common carotid 

artery was scanned in the longitudinal direction. The software 

was designed in MATLAB software to extract consecutive 

images in the bitmap image file (BMP) format from the AVI 

movies. This software provided the image dimensions (the 

images were 547 × 692 pixel 2 ), image type (B-mode), and 

pixel dimensions (0.063 × 0.063 mm 2 ). 

Because the far wall has better reflections due to the 

interface blood-intima-media layers and the arterial wall on 

the far side from the transducer are thus more convenient 

for measurements, 1 the measurement of the radial movement 

based on the block-matching algorithm was performed using 

ROI with a size of approximately 53 × 42 pixel 2 on the intimamedia 

thickness of the posterior wall of the artery. The second 

algorithm was thereafter implemented; the reference points 

were selected in the first frame approximately at the center 

of the reference block of the block-matching algorithm. Then 

the blood-intima boundary was searched in the perpendicular 

direction and the points with maximum gradients were picked 

up, with the best candidates being those with the least cost 

function (Figure 1). 

Figure 1. Wall motion detection in two sequential frames by block-matching 

algorithm (A), and maximum-gradient algorithm (B). Arrows show region 

of interest 

Our ultrasonic image pixel had a dimension of 0.06 × 0.06 

mm 2 . By interpolating, 100 boundary points were obtained; 

and by considering the measurements in two cardiac cycles, 

measuring error would become less than 0.003 mm. 

All the data are expressed as mean ± standard deviation 

(SD). The data were tested for normal distribution and 

homogeneity of variance by the Kolmogorov-Smirnov 

test (K-S) and Levene test, respectively. In the pilot study, 

we extracted 200 arterial displacements from the images 

of 4 subjects. The maximum sample size for the Pearson 

correlation analysis was estimated on 11 images with a 

confidence level of 95% and power of test of 90%. The 

Pearson linear correlation and the Bland-Altman analysis 12 

with a 95% limit of agreements (LOA) (i.e., mean difference 

± 1.96 SD of the difference) were calculated to assess the 

relationships between the two methods, block-matching 

algorithm and combination of dynamic programming and 

maximum-gradient algorithm for the motion estimation 

of the arterial walls. A comparison of the differences of 

the maximum and the mean of the radial displacements of 

the right common carotid artery was done with the paired 

samples t-test. The results were considered significant 

when the probability value was < 0.05. Intraobserver and 

interobserver variability was defined as differences between 

the two measured methods and expressed as a percentage 

error of the means and was carried out as follows: 

The images of one random subject were examined by 

two observers: the person who had examined all the other 

images and another observer. Each of them evaluated the 

radial movement of the arterial wall three times using each 

algorithm. The percentage of the coefficient of variation was 

74


defined as: 

Where SD and mean value are standard deviation and 

mean value of the measurements using each algorithm, 

respectively. 

All the statistical analyses were performed using the SPSS 

software package (SPSS Inc. Chicago, IL, USA). 


block-matching and the maximum-gradient algorithms. The 

correlation between the values of the block-matching analysis 

and the maximum-gradient tracing was assessed by the 

Pearson correlation analysis. The Pearson linear correlation 

coefficients were calculated to analyze the similarity between 

the displacement waveforms acquired from the two methods 

for our 10 subjects with 200 frames for each ones (Table 1). 

Results 

For one of the subjects, the radial displacement waveforms 

at each frame via the block-matching and maximum-gradient 

algorithms are depicted in Figure 2, which demonstrates a 

good agreement between the waveforms. 

Figure 3. The mean ± standard deviation of the maximum and mean radial 

displacement of the carotid artery wall for the 10 subjects obtained via the 

block-matching and maximum-gradient algorithms 

Figure 2. Radial displacement waveform (mm) of the carotid artery wall 

obtained from the block-matching and maximum-gradient algorithms 

The maximum and the mean of the radial displacements of 

the right common carotid artery were extracted throughout 

two heart cycles via the block-matching algorithm and 

maximum-gradient algorithm in the 10 healthy subjects. 

The results are shown in Figure 3. The measurements of 

the maximum and the mean radial displacements using the 

block-matching algorithm are respectively 0.06 and 0.04 mm 

greater than the values obtained from the maximum-gradient 

algorithm. 

The statistic analysis showed no differences between the 

two methods of the block-matching and the maximumgradient 

algorithms (p value > 0.05). The coefficients of 

variation percent (CV %) for the arterial displacements in 

the block-matching and the maximum-gradient algorithms 

were 0.47% and 0.04%, respectively. 

This study compares the relation between radial 

displacements measured by automated methods, i.e. the 

Table 1. The Pearson linear correlation coefficients and p values for the wall 

radial movement of the common carotid artery of the 10 healthy subjects 

Subject Correlation coefficient P value 

1 0.876 0.000 

2 0.966 0.000 

3 0.938 0.000 

4 0.969 0.000 

5 0.901 0.000 

6 0.908 0.000 

7 0.868 0.000 

8 0.777 0.000 

9 0.988 0.000 

10 0.848 0.000 

There was a high correlation between the radial 

displacement as measured by the two methods, namely 

the block-matching algorithm and the maximum-gradient 

algorithm (R = 0.89, p value < 0.05) (Figure 4). 

By the linear regression analysis, the regression function 

between the radial displacements measured by the blockmatching 

and the maximum-gradient tracing methods was 

predicted as: D MG 

= 0.847 × D BM 

-0.003, where D MG 

and D BM 

are radial displacements measured by using the maximumgradient 

and block-matching algorithms, respectively. The 

radial displacements in the right common carotid artery 




measured by the block-matching algorithm method were 

significantly correlated to the radial displacements measured 

by the maximum-gradient algorithm manual method 

(p value < 0.05). 

(LOA) (Figure 5). 

Confidence interval was 95%. There was a high agreement 

between the two methods. The mean difference between the 

estimated displacement and measured displacement was 

-0.044 ± 0.038 mm. The Bland-Altman analysis results 

confirmed a good agreement between the two methods in 

measuring the radial movement (Figure 5). 

Table 2 shows the frame number in which maximum 

displacement of each cardiac cycle of the subjects occurred 

for both algorithms. As it can be seen, both methods found 

the maximum displacement occurring in the same frames (± 

1 frame) and just in three cycles; this difference is more than 

one frame. 

Figure 4. Scatter plot demonstrating the correlation between the radial displacements 

(mm) of the right common carotid artery as measured by the 

block-matching method (D BM 

) and the maximum-gradient method (D MG 

) 

Table 2. Frame number in which maximum displacement was found by 

each algorithm 

Subject 

Block 

matching 

algorithm 

First maximum 

(Frame No.) 

Maximum 

gradient 

algorithm 

Second maximum 

(Frame No.) 

Block 

matching 

algorithm 

Maximum 

gradient 

algorithm 

1 16 15 53 50 

2 8 8 31 32 

3 9 9 39 40 

4 7 7 42 43 

5 8 8 37 36 

6 16 17 39 40 

7 13 10 40 40 

8 8 8 31 31 

9 6 6 31 31 

10 7 7 34 37 

The intraobserver and interobserver variability of maximum 

and mean radial displacement was 0.47% and 0.48% for the 

block-matching algorithm and 0.04% and 0.09% for the 

maximum-gradient algorithm, respectively. 

Discussion 

Figure 5. Relative Bland-Altman plot of the difference between arterial wall 

displacement changes estimated based on the block-matching method and 

maximum-gradient method. The outer lines represent 2 standard deviation 

or the 95% limits of agreement 

For the Bland-Altman analysis, the difference between 

the arterial wall displacement changes estimated from the 

regression function and changes displacement measured by 

using the block-matching algorithm was plotted against the 

average of both observations. The middle line indicates the 

average difference between the two methods, whereas the 

outer lines represent 2SD or the 95% limits of agreement 

Because of the important role of the arterial wall motion 

in discriminating mechanical properties between healthy 

and diseased vessels, several methods have been used 

for evaluating the mechanical properties of arteries. 13-15 

Among them, ultrasonography, as a non-invasive, safe, and 

cost-effective method, has always been of great interest 

for estimating both motion amplitude and direction from 

temporal consecutive images. 16-18 

In this study, we showed that high resolution B-mode 

ultrasound can be used to evaluate the mechanical properties 

of the arterial wall by calculating the displacement of the 

arterial wall during cardiac cycles using a computerized 

analyzing method. The interface location is commonly 

determined by using computer-based interactive tracing 

systems. Efforts have been made to make the measurement 

less operator-dependent by introducing automated 

76


image analysis procedures. The two methods of blockmatching 

algorithm and a combined algorithm of dynamic 

programming and maximum-gradient are implemented for 

measuring the arterial wall changes of the common carotid 

in healthy subjects. 

Two-dimensional block-matching time domain approaches 

to speckle tracking have found widespread application 

because of their inherent simplicity and relative immunity to 

noise. 7 Golemati et al. demonstrated that the two-dimensional 

motion of the normal and diseased arterial wall as well as 

the surrounding tissue can be accurately quantified through 

cross-correlation. 5, 19 They compared block matching and 

optical flow and the effect of the block size on the arterial 

wall motion estimation of 10 healthy subjects in both radial 

and axial directions. 3 They also attempted to combine a 

FIELD-Π software based ultrasound simulation approach 

with mathematical modeling of the arterial wall motion. The 

simulated sequential image data may be used to evaluate the 

performance of motion analysis algorithms. 7 Persson et al. 

designed and demonstrated a new non-invasive method for 

longitudinal and circumferential movement estimation. 20 

Cinthio et al. evaluated this echo-tracking system based 

on block matching for measuring radial and longitudinal 

movements of small regions of the intima-media complex 

of the arterial wall. They subsequently used this to estimate 

the longitudinal movement and resulting shear strain of the 

arterial wall. 21 

Other different image analysis algorithms have been 

investigated for automated ultrasonic boundary detection. 

These are the dynamic programming, maximum gradient, 

model-based, and matched filter algorithms. These methods 

were implemented to measure the intima-media thickness 

and internal diameter of arteries; and among them, dynamic 

programming and maximum gradient have the highest 

1, 4, 22 

accuracy. 

Wendelhag et al. used the dynamic programming algorithm 

for developing a computerized analyzing system to evaluate 

the boundaries of the intima-media. 23 Chang et al. proposed 

an automatic system for detecting the intima-media thickness 

of the common carotid artery using the snake techniques. 

They showed that the computerized system had the potential 

in automatically detecting the intimal and adventitial layers 

without any manual correction. 24 Jegelevicius et al. employed 

the dynamic programming and maximum-gradient algorithms 

for measuring the intima-media thickness in a single frame, 

separately. 

They suggested the maximum gradient for intima-media 

thickness measurement. 15 But all of the above-mentioned 

studies, was used the computerized analyzing method for 

detecting the lumen diameter or intima-media thickness in a 

single frame, and method for making the actual measurements 

over the entire cardiac cycle to capture the dynamic nature of 

the vessel are spars. 

In the present study, we detected the absolute carotid 


artery wall displacement in the radial direction by tracking 

the location of a block and using a maximum-gradient-based 

algorithm. The echo-tracking algorithm has been used most 

frequently in the studies on the arterial wall motion due 

to its computational simplicity and accuracy. On the other 

hand, ultrasonic boundary detection algorithms based on the 

maximum gradient and dynamic programming have been 

rarely used to extract arterial wall motion. The results of the 

present study showed that in conjunction with the arterial 

intima-media thickness and internal diameter measurements, 

boundary detection algorithms can be used for arterial wall 

motion detection. From the computation complexity view, 

maximum gradient was higher than block matching, and 

it required manually placing the approximate boundary 

points and was more time-consuming. The most important 

advantage of maximum gradient over block matching is its 

ability to detect the coincidental waveforms of the anterior 

and posterior wall motion and thus the arterial diameter 

changes. 

The results of the presents study showed that the maximum 

and mean radial displacements acquired from block matching 

were respectively 0.06 and 0.04 mm greater than the values 

gained from maximum gradient. Regarding the pixel size, 

the differences had the order of one pixel size. The greater 

values of the block-matching measurements can be related to 

its more accurate searching method. In the block-matching 

techniques, the intensity of a block of pixels is compared 

with the reference frame and the best match is found by 

maximizing the similarity. Consequently, more accurate 

two-dimensional tracking is possible. But in maximumgradient-based 

algorithms, searching is performed in just 

one direction, perpendicular to the boundary, and the point 

of maximum intensity gradient is picked up. Thus, with the 

presence of echo-dropout, it fails to track the boundary and 

the average of neighboring points is replaced. 

Our regression analysis demonstrated a good correlation, 

with a correlation coefficient of 0.89, between the two 

methods in measuring the radial displacement of the carotid 

artery wall. The Bland-Altman statistical analysis, with the 

mean difference and limits of agreement of -0.044, -0.12 

and 0.032 respectively, confirmed this correlation. Low 

dispersion coefficients showed high reproducibility of both 

methods, higher for the maximum-gradient method. 

Despite the differences in the radial displacements obtained 

from the two algorithms, it is notable that in seventeen out 

of twenty cardiac cycles, maximum displacements occurred 

in the same (± 1) frame, showing the coincidence of cardiac 

events for both algorithms. 

Conclusion 

The results of the present study showed that both blockmatching 

and maximum-gradient algorithms can be used 




to extract the radial displacement of the carotid artery wall; 

and regarding the pixel size as error, the same results can be 

obtained. In spite of the two-dimensional searching of the 

block-matching algorithm, maximum gradient seems to have 

higher reproducibility and is more user-friendly. Thus we 

suggest the maximum-gradient algorithm for further studies 

on the radial movement of the arterial wall. 


We want to thank Dr S. Shams Hakimi for their valuable 

technical assistance. This study has been approved by 

Institutional Review Board and Ethics Committee of Tarbiat 

Modarres University. 

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78



Transcatheter Closure of Atrial Septal Defect with 

Amplatzer Septal Occluder in Adults: Immediate, Short, 

and Intermediate-Term Results 

Mostafa Behjati, MD * , Mansour Rafiei, MD, Mohammad Hossein Soltani, MD, 

Mahmoud Emami, MD, Majid Dehghani, MD 

Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 

Received 31 March 2010; Accepted 05 February 2011 

Abstract 

Background: The transcatheter closure of the atrial septal defect (ASD) has become an alternative technique to surgical 

procedures. The aim of this study was to assess the immediate, short, and intermediate-term results of the transcatheter 

closure of the secundum ASD with the Amplatzer Septal Occluder (ASO) in adult Iranian patients. 

Methods: Between December 2004 and July 2008, the transcatheter closure of the ASD using the ASO was attempted in 58 

consecutive, adult patients. The mean age of the patients was 37.1 ± 12.7 years (range = 19 - 75 years). 

All the procedures were performed under local anesthesia with transthoracic or transesophageal echocardiography and 

fluoroscopic guidance. The stretched diameter of the ASD was determined with a balloon sizing catheter, and device selection 

was based on and matched to the stretched diameter of the septal defect. 

Transthoracic echocardiography was performed immediately after the release of the device and before discharge. 

Further follow-up at one month, six months, and yearly thereafter included physical examination, electrocardiography, and 

transthoracic echocardiography. 

Results: The mean ASD diameter, as measured by esophageal echocardiography, was 24.8 ± 5.4 mm (range = 13 - 34 mm). 

The mean stretched diameter, as measured by the balloon catheter, was 27.1 ± 6.4 mm (range = 12.5 - 39 mm). Deployment 

of the ASO was successful in 52 (89.6%) patients and failed in 6 (10.4%). Four patients experienced severe complications, 

1 had tamponade requiring drainage, 2 had device embolization to the left atrium and right ventricular outflow tract, and 1 

had late wire fracture (surgical removal and repair of the ASD). The position of two large devices (34 mm and 36 mm) was 

considered unsuitable and unstable after implantation and resulted in the removal of these devices. 

Minor complications included transient complete atrioventricular block in 1 patient, paroxysmal supra tachycardia in 3 

patients, atrial flutter in 1 patient, and angina pectoris with transient ST elevation in 2 patients. The mean follow-up period 

was 32.5 ± 18.5 months. Echocardiography at 24 hours, 1 month, 6 months, and 12 months after the procedure showed 

residual shunts in 11 (21%), 3 (5.8%), 2 (3.8%), and 2 (3.8%) patients, respectively. At follow-up (12.8 months to 48.5 

months, mean ± SD = 32.5 ± 18.5 months), complete closure was documented in 50 (96.2 %) of the 52 cases. At the end of the 

follow-up, 2 (3.8%) patients had residual shunts: The shunt was moderate in 1 (1.9%) patient and small in the other (1.9%). 

The overall success rate of the transcatheter closure of the ASD was 86% (50 of 58 cases). 

Conclusion: The transcatheter closure of the secundum ASD in our adult patient population using the ASO was associated 

with high degrees of success, minimal procedural complication rates, and excellent short and midterm results. The use of this 

device, however, requires thorough attention in that the procedure may be ineffective or the device may embolize. Further 

experience and long-term follow-up are required before a widespread clinical use can be recommended. 


* 

Corresponding Author: Mostafa Behjati, Associate Professor of Pediatric Cardiology, Division of Pediatric Cardiology, Shahid Sadoughi University of Medical 

Science, Afshar Hospital, Jomhouri Boulevard, Yazd, Iran. 8917945556. Tel: +98 351 5231421. Fax: +98 351 5253335. E-mail: dr_behjati@yahoo.com. 



Mostafa Behjati et al. 

This paper should be cited as: Behjati M, Rafiei M, Soltani M. H, Emami M, Dehghani M. Transcatheter Closure of Atrial Septal Defect 

with Amplatzer Septal Occluder in Adults: Immediate, Short, and Intermediate-Term Results. J Teh Univ Heart Ctr 2011;6(2):79-84. 

Keywords: Septal occluder device • Heart septal defects, atrial • Adult • Treatment outcome 

Introduction 

The atrial septal defect (ASD) is the third most common 

form of congenital heart anomalies. 1 For several decades, 

surgical closure has been considered the standard method of 

repairing a secundum ASD. 2 Surgical repair, albeit enjoying 

a high success rate, negligible mortality, and good longterm 

outcome, is associated with morbidity, discomfort, and 

thoracotomy scars. 3 That is why the transcatheter closure 

of the ASD has more recently become an alternative to the 

surgical procedure .4 The transcatheter closure of the ASD was 

first described by King et al. in 1976. 5 Currently, there are 

multiple devices clinically available with variable degrees of 

success; none of them, however, is fully satisfactory inasmuch 

as they cannot be utilized to completely close defects > 20 

mm and they frequently allow residual shunting. 6 

During the last decade, the Amplatzer septal occluder 

(ASO), with its unique design and easy handling, has finally 

replaced surgical ASD repair in most adult patients as the 

standard method of repair for the secundum ASD. 7, 8 We 

herein report our immediate, short, and intermediate-term 

results of the ASO use for the non-surgical transcatheter 

closure of the ASD in adults. 

Methods 

Between December 2004 and July 2008, 58 out of 68 

consecutive patients with a significant ASD, as demonstrated 

by initial transthoracic echocardiography (TTE), were 

considered for transcatheter closure with the ASO. The 

inclusion criteria for the patients with the ASD were: (1) the 

presence of a secundum ASD with a significant left-to-right 

shunt (pulmonary to systemic flow ratio [QP/QS] ≥ 1.5/1); 

(2) an ASD with a balloon stretched diameter ≤ 39 mm with 

a suitable septal rim of at least 5 mm from the mitral and 

tricuspid valves; and (3) right ventricular overload. Ten 

patients were excluded from the analysis for the following 

reasons: (1) The defect was too large for occlusion (1 

patient); (2) there was severe pulmonary artery hypertension 

(pulmonary artery systolic pressure > 80 mmHg and 

pulmonary artery resistance > 8 woods) (2 patients); and 

(3) there were small superior, inferior, or posterior rims of 

the ASD during the TEE examination or balloon stretch 

sizing (6 patients). One patient showed drainage of the 

right pulmonary vein into the superior vena cava. Finally, 

58 patients underwent the transcatheter closure of the ASD 

with the ASO. Informed consent was obtained from all the 

patients or their guardians. 

The principle of the device is based on the conjoint waist 

''stenting'' the ASD, providing both fixation and occlusion. 

The ASO is a self-centering and self-extracting occlusion 

device made from a nitinol wire mesh forming a left atrial 

retention disc, a self-centering stent, and a right atrial disc. 

The ASO is available in sizes with one-mm increments from 

four mm to twenty mm and then in two-mm increments up to 

the current largest device of forty mm. The device is attached 

to a delivery cable by a central screw at the proximal end 

of the device, and it is compressed into a loader by pulling 

on the delivery wire. A 6F to 12F delivery sheath is used 

depending on the required size of the device. 

Before catheterization, all the patients were evaluated via 

transthoracic (TTE) and transesophageal echocardiography 

(TEE) was conducted under local anesthesia and moderate 

conscious sedation with midazolam (3-5 mg) using a Hewlett- 

Packard Sonos 4000 or Vivid 4 (QE- Vingmed Ultrasound 

AS) echocardiography device and a nine-MHZ probe to 

evaluate the size, location, and margin of the defect. 

All the procedures were performed under local anesthesia 

and moderate sedation, with transthoracic and fluoroscopy 

guidance throughout. First, a standard right-heart 

catheterization was carried out through the right femoral vein 

with recording of the blood pressure and blood sampling to 

calculate the QP/QS ratio. The right upper pulmonary vein 

angiography in the hepatoclavicular view was performed to 

visualize the atrial septum. 

For endocarditis prophylaxis, the patients received 

cefazolin (1g IV) thirty minutes before the procedure, 

followed by 1g IV every eight hours for an additional two 

doses. After sheath placement, all the patients received 

intravenous heparin (100 IU/kg) and maximum 5000 IU was 

administered intravenously. 

A sizing balloon catheter (AGA Medical Golden Valley, 

MN) was inflated at the level of the defect until the waist 

in the middle of the balloon was seen (Figure 1). The waist 

was measured and calibrated on the cine-angiographic frame 

together with a calibrated template. A device with a waist 

diameter similar to the stretched ASD diameter; or in the 

large defects, up to two mm larger than the stretched ASD 

diameter, was chosen. The selected ASO was attached to 

the delivery cable via the screw mechanism and was loaded 

by being withdrawn into the loader through traction on the 

delivery cable. 

80

Transcatheter Closure of Atrial Septal Defect with Amplatzer Septal Occluder ... 


Figure1. Sizing procedure using sizing balloon catheter; waist of the balloon 

clearly indicates the stretch diameter of the atrial septal defect (arrows) 

A 

The compressed ASO was then advanced through the long 

sheath that had previously been positioned in the left atrium. 

Under fluoroscopic control, the left atrial disc was extruded 

by advancing the delivery cable. After the distal disc was 

deployed in the middle left atrium, the delivery system was 

gently pulled back against the atrial septum. The ASO was 

thereafter fully deployed by withdrawing the sheath over the 

delivery cable to expand the right atrial disc. The position and 

stability of the ASO was assessed by fluoroscopy and TTE. 

Care was taken to ensure that the device did not obstruct 

the right pulmonary veins, caval veins, coronary sinus, or 

the mitral valve. Any residual shunt was evaluated by twodimensional 

color-flow Doppler. The residual shunt was 

defined as a leak traversing or passing between the two discs 

of the ASO or around the device edges to the right atrium and 

was detected by two-dimensional color-flow Doppler. The 

residual shunt was classified according to the color-jet width 

describe by Boutin and her colleagues 10 as trace < 1 mm, 2 

mm > small > 1mm, 4 mm > moderate > 2 mm, and large 

> 4 mm. If the width of the color Doppler flow was < 2mm, 

2-4mm, and > 4mm; the residual shunts were classified as 

mild, moderate, and severe, respectively. The device was 

subsequently released from the delivery system, and final 

assessment of the position of the device was made via TTE. 

After the release of the device, right atrium angiography 

with follow-through was carried out in the hepatoclavicular 

projection (Figure 2). 

As a matter of routine, after ASD closure, the patients 

remained in the general ward of the hospital for one night 

and received heparin 100 IU/kg/daily (partial thromboplastin 

time [PTT] 50-60 seconds) for twenty-four hours. TTE was 

performed twenty-four hours after the procedure and before 

hospital discharge to ensure the suitable deployment of the 

device and to look for any residual shunt. 

B 

C 

Figure 2. Transcatheter closure steps by fluoroscopy. Deployment of the left 

and right discs of an Amplatzer device with the central waist stenting the 

atrial septal defect (A); contrast injection in right atrium showing suitable 

device position and no residual shunt through the device (B); and complete 

deployment of the Amplatzer septal occluder after release of device from 

delivery cable (C) 



The patients were discharged on ticlopidine (250 mg/ 

day) for one month and aspirin (80 mg/day) for six months 

in order to prevent excessive thrombus formation on the 

device. Standard bacterial endocarditis prophylaxis was 

recommended for six months or until complete closure had 

been achieved. Repeat TTE was performed one, six, and 

twelve months after the procedure and yearly thereafter. 

Efficacy was defined as the successful closure of the 

defect without residual shunts or only trivial shunts after six 

months, and safety was defined as the avoidance of death 

or major complications such as cerebral embolism, cardiac 

tamponade, device embolization or dislodgement requiring 

open cardiac surgery, and infectious endocarditis. TTE is 

a reliable technique for the evaluation of residual shunts; 9 

therefore, residual shunting in the wake of device closure 

was evaluated via two-dimensional color-flow Doppler 

echocardiography. 10 

All the data were collected on a set data sheet, collated by 

a single coordinator, and entered into a common database 

for analysis. The data were expressed as mean ± standard 

deviation, median, range, and percentage. The data were 

analyzed using the SPSS software version 13.0. 

Results 

Between December 2004 and July 2008, the transcatheter 

closure of the ASD was conducted in 58 of 68 consecutive 

patients who presented at our institution. On account of the 

fact that the position of two large devices (34 mm, 36 mm) 

was considered unstable or unsuitable after implantation, 

these two devices were not released and were withdrawn. 

There were four major procedure-related complications. 

The ASO was successfully implanted in 52 patients (female/ 

male: 3.3/1). 

The patients’ demographics and procedure characteristics 

are depicted in Table 1. 

The mean age of the study population was 37.1 ± 12.7 

years (median = 36 years, range = 19 - 75 years). The mean 

body weight was 59.9 ± 11.5 kg (median = 58 kg, range = 

42 - 88 kg). On TEE, the mean defect diameter was 24.8 ± 

5.4 mm (median = 26 mm, range = 13 - 34 mm). 

The balloon stretch diameter of the ASD varied between 

12.5 and 39 mm (mean = 27.1 ± 6.4 mm).The pulmonary to 

systemic shunt ratio (QP/QS) ranged from 1.6 to 5.8 (mean 

2.7 ± 0.85). The average pulmonary artery pressure was 23.4 

± 7 mmHg (range = 12 - 48 mmHg). The average procedure 

time and fluoroscopy time were 46.1 ± 12.9 minutes (range 

= 25 - 80 minutes) and 8.9 ± 4.1 minutes (range = 3.8 - 20 

minutes) respectively, with a tendency to shorter procedural 

and screening time after the learning curve. The mean 

follow-up period was 32.5 ± 18.5 months (range = 12.8 - 

48.5 months). 

At the end of the procedure, on color flow Doppler, residual 


shunting (including foaming through the wire mesh of the 

device.) was seen in 30 (58%) of the 52 patients. By the time 

of discharge, the rate of the residual shunt had decreased to 

21% (11 patients). The residual shunt remained persistent, 

however, 6 months after the procedure in 3 patients. At the 

end of the follow-up, the residual shunt was detected in 2 

patients. One patient with a mild residual shunt at the time of 

discharge worsened; the shunt was adjudged moderate one 

month after the procedure and this moderate shunt persisted 

at one year’s follow-up. 

Repeat TTE at twelve months’ follow-up showed device 

wire fracture and malposition to the right atrium. The device 

was removed at surgery, during which the ASD was closed 

as well. Finally, follow-up echocardiography at twentyfour 

hours, one month, six months, and one year after the 

procedure showed complete closure rates of 79%, 94.2%, 

94.2%, and 96.2%, respectively (excluding 4 patients with 

major complications and 2 patients with unstable-unsuitable 

device position). 

There were 4 major procedure-related complications: 

one device embolization to the right ventricle, one device 

embolization to the left atrium, one left atrium perforation, 

and one device wire fracture. The left atrium perforation case 

and cardiac tamponade necessitated emergency surgery. The 

embolized devices were retrieved at surgery, during which 

the ASD was closed without further complications. There 

was no cardiac death during the study. 

There were 7 other documented complications. Two 

patients developed transient ST-elevation, which cleared 

within a short period of time; these were attributed to 

small air emboli. Another patient developed transient 

complete atrioventricular block during the manipulation 

of the delivery system and the ASO in the left atrium; it 

cleared spontaneously and was not associated with any 

hemodynamic compromise. Three patients presented with 

supraventricular tachycardia, which was spontaneously 

resolved in 2 patients and was reverted in the other case with 

verapamil. A 45-year-old women developed persistent atrial 

flutter one month after uncomplicated ASD closure with a 

36-mm ASO. In this patient, long-term maintenance of sinus 

rhythm was achieved with propranolol and amiodarone. One 

patient had a new onset of migraine-type headaches during 

the first month after the procedure, which was spontaneously 

resolved six months subsequently. 

At a mean follow-up period of 32.5 ± 18.5 months 

(range = 12.8 - 48.5 months, median = 30 months), all the 

defects, with the exception of two cases with moderate and 

small shunts, were completely closed and remained closed 

afterwards. Also, the integrity of the ASO was evaluated 

using echocardiography in all the cases. One late device wire 

fracture was observed; the device was retrieved at surgery 

and the ASD was closed at the same time. 

82

Transcatheter Closure of Atrial Septal Defect with Amplatzer Septal Occluder ... 


Discussion 

The percutaneous closure of the ASD first and foremost 

obviates thoracotomy, open heart surgery, and admission to 

an intensive care unit and thus avoids subsequent surgical 

scars and postoperative pain. The other advantages of 

this treatment modality include fewer psychological 

impacts, shorter hospital stays, and lesser need for 

blood transfusion. 11, 12 Furthermore, the absence of atrial 

myocardial scar may reduce the incidence of incisional 

dysrhythmias. 11 

The transcatheter closure of the ASD is an established 

technique with a low incidence of morbidity and mortality, 

and an important advantage of the ASO is that it can be 

easily retrieved into the delivery sheath and re-deployed 

several times before final release. This greatly diminishes the 

risk of the malposition and embolization of the device. We 

believe that a thorough device size selection is of paramount 

importance; this depends on an accurate assessment of the 

stretched diameter of the ASD because the device is matched 

to the size of the stretched ASD diameter. An oversized device 

can cause the distortion of the retention discs and impinge on 

sensitive structures, while an undersized device may result in 

residual shunting and the early or even late embolization of 

the device. TEE monitoring of the procedure to ensure the 

correct positioning of the device before and after its release 

is also essential. In our study, the devices were deployed 

without TEE monitoring, as a result of which the chance of 

embolization of the device increased significantly (2 cases 

[3.5%]) 

After the deployment, the residual shunt is a major concern 

when a septal occluder is employed for the transcatheter 

closure of the ASD. In our patients, there was 1 small and 1 

clinically important residual shunt at one year’s follow-up. 

A small residual shunt after device closure does not seem to 

lead to long-term problems. The low incidence of residual 

shunts could be an important advantage for the ASO over 

other devices designed for the closure of the secundum 

ASD. 13 

Cardiac perforation is a rare procedure-related 

complication. 14 In our study, cardiac perforation occurred 

in the antero-superior atrial wall; the patient underwent the 

surgical repair of the perforation and closure of the ASD. 

The ASO-associated cardiac perforation has been recorded 

predominantly in the antero-superior atrial wall and/or the 

adjacent aorta. 14 

In our study, embolization occurred in 2 (3.5%) patients. The 

device was deployed without TEE monitoring, resulting in a 

significant occurrence rate of device embolization. Residual 

shunts and serious complications have low incidence post- 

ASO implantation. 9, 15, 16 In our experience, the incidence of 

the residual shunt was low and only 1 (1.9%) patient had a 

moderate residual shunt at mid-term follow-up. Chiming in 

with other studies, device embolization /malposition was the 

most common major complication in our study. 17-20 Overall, 

the literature supports the notion that the treatment of the 

secundum ASD via transcatheter occlusion is associated with 

complications, but the trend is towards lower complications 

using the newer transcatheter with the ASO. Avoidance of 

complications is dependent on careful case selection, sizing 

of the defect, selection of the suitable size of the device, 

prevention of air embolism, and TEE monitoring during the 

transcatheter procedure. 

The results of our study of the transcatheter ASD closure 

with the ASO in 52 patients, with a complete occlusion rate 

of 79% (41 cases) at twenty-four hours, 94.2% (49 cases) at 

one month, 94.2% (49 cases) at six months, and 96.2% (52 

cases) at twelve months and the overall success rate of 86% 

(50 of 58) (including complications and residual shunts), 

concur with the results reported in previous studies. 19-23 Our 

results demonstrate that the ASO device is particularly useful 

in most adults with the secundum ASD. 

Table1. Patients’ demographic and procedural details, n=52 

Mean SD Median Range 

Age (y) 37 12.7 36 19-75 

Gender (F/M) - - - 3.3/1 

Weight (kg) 59.9 11.5 58.2 42-88 

QP/QS 2.7 0.85 2.5 1.6-5.8 

Average PAP (mmHg) 23.4 6.98 23 12-48 

Size of ASD with TEE 24.8 5.4 26 13-34 

Size of ASD with SBC (mm) 27.1 6.4 27.5 12.5-39 

ASO size (mm) 27.9 6.2 28 14-40 

FT (min) 8.9 4.1 7.30 3.8-20 

PT (min) 46.1 12.9 44 25-80 

F/U (mo) 32.5 18.5 30 12.8-48.5 

SD, Standard deviation; F, Female; M, Male; QP/QS, Pulmonary to systemic flow ratio; PAP, Pulmonary artery pressure; ASD , Atrial septal defect, 

TEE, Transesophageal echocardiography; SBC, Sizing balloon catheter; ASO, Amplatzer septal occluder; FT, Fluoroscopy time; PT, Procedure time; 

F/U, Follow-up 



Conclusion 

In summary, the ASO can be used successfully to close 

selected secundum ASDs in most adult patients with low 

complication rates and good short and intermediate-term 

outcomes. Be that as it may, the utilization of this device 

requires careful attention in that the procedure may be 

unsuccessful or the device may embolize. Strict case selection 

criteria, expertise, and meticulous device selection may help 

reduce, although not completely eliminate, the incidence of 

complications such as device embolization. The device may 

show short and intermediate-term good results but further 

experience and long-term observation of patients treated 

with the transcatheter procedure is needed in order to draw 

definite conclusions. 

Acknowledgements 

Mostafa Behjati, MD, was supported in part by a grant 

from the Yazd Cardiovascular Research Center and Shahid 

Sadoughi University of Medical Sciences. We thank MH 

Ahmadieh, PhD, for statistical analysis. 

We gratefully acknowledge Majid Dehghani, MD, who 

helped to establish this procedure in Afshar Hospital. 

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84


Case Report 

Incidental Finding of Cor Triatriatum Sinistrum in a 

Middle-Aged Man Candidated for Coronary Bypass 

Grafting (with Three-D Imaging) 

Afsoon Fazlinezhad, MD * , Farveh Vakilian, MD, Asadollah Mirzaei, MD, Azadeh 

Fallah Rastegar, MD 

Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. 

Received 21 August 2010; Accepted 30 March 2011 

Abstract 

Cor triatriatum sinistrum is a rare congenital cardiac malformation, accounting for about 0.1-0.4% of all congenital heart 

diseases and characterized by the presence of a fibromuscular membrane that subdivides the left atrium into two chambers in 

the classical form. While classic cor triatriatum in most patients can be observed during the neonatal period or early infancy, 

it is very rare in adults. 

We herein present an incidental finding of cor triatriatum sinistrum in a middle-aged man with coronary artery disease 

scheduled for coronary artery bypass graft surgery. The patient was admitted for exertional dyspnea and chest pain of a 

three-month duration. He had a past medical history of mild hyperlipidemia and mild hypertension. Transthoracic two-D 

echocardiography (TTE) demonstrated a visible presence of a membranous band in the mid portion of the left atrium with 

obvious obstruction by color and Doppler flow measurements, confirmed by three-D echocardiography. Selective coronary 

angiography also revealed a severe ostioproximal stenosis of the left anterior descending artery of up to 99%. 

On-pump coronary artery bypass grafting was performed without complications, during which the anastomosis of the left 

internal mammary artery to the left anterior descending artery and the removal of the membrane were done. 


This paper should be cited as: Fazlinezhad A, Vakilian F, Mirzaei A, Fallah Rastegar A. Incidental Finding of Cor Triatriatum Sinistrum 

in a Middle-Aged Man Candidated for Coronary Bypass Grafting (with three-D imaging). J Teh Univ Heart Ctr 2011;6(2):85-88. 

Keywords: Cor triatriatum • Coronary artery disease • Coronary artery bypass • Heart defects, congenital 

Introduction 

Cor triatriatum sinistrum is a rare congenital cardiac 

anomaly and is responsible for 0.1 - 0.4% of all congenital 

cardiac malformations, without any known associated 

genetic abnormalities. 1, 2 The clinical manifestations of this 

defect are dependent on the size of the ostia. 3, 4 In adults, 

however, the clinical manifestations are often delayed due 

to the presence of a large opening. This is a report of cor 

triatriatum sinistrum diagnosed incidentally, late in the 5 th 

decade of a man’s life, during a preoperative study. 

Case Report 

This is a report of cor triatriatum sinistrum diagnosed 

* 

Corresponding Author: Afsoon Fazlinezhad, Associate Professor of Cardiology, Fellowship of Echocardiography, Echocardiography Department, 

Ghaem University Hospital, No. 38, 5th North Daneshsara Street, Sanabad Ave., Mashhad, Iran. 9184713153. Tel: +98 9153134470. Fax: +98 5118414773-4. 

E-mail: fazlinejada@mums.ac.ir. 



Afsoon Fazlinezhad et al. 

incidentally, late in the 5 th decade of a man’s life, during 

a preoperative study. A 42-year-old Asian male was 

admitted for exertional dyspnea and chest pain of a threemonth 

duration. He had a past medical history of mild 

hyperlipidemia and mild hypertension, and his medications 

included enalapril, hydrochlorothiazide, metoprolol, and 

aspirin. 

Cardiovascular examination revealed normal first heart 

sound and physiologically split second heart sound in 

conjunction with grade 2/6 systolic murmur at the left sternal 

border, which was intensified by inspiration. No significant 

laboratory abnormality was detected on admission. The 

patient’s electrocardiogram (ECG) was normal and his 

previous exercise tolerance test was positive; he was, 

therefore, scheduled for selective coronary angiography 

and transthoracic two-D echocardiography (TTE) to 

be performed for left ventricular function study. TTE 

demonstrated a normal-sized left ventricle with a normal 

ejection fraction of about 60%; normal right ventricular size 

and function; a mildly enlarged left atrium; and a visible 

presence of a membranous band in the mid portion of the left 

atrium with obvious obstruction by color and Doppler flow 

measurements, confirmed by three-D echocardiography 

(Figure 1). The two-D findings were further confirmed by 

transesophageal echocardiography (TEE), which visualized 

an obstructing fibromuscular membrane distal to the 

pulmonary veins and proximal to the left atrial appendage 

in multiple views (Figures 2 and 3). In addition, the orifice 

was about 11 mm in diameter with a mean pressure gradient 

of about 5.94 mmHg (Figure 4). The findings of two-D 

echocardiography and TEE substantiated the diagnosis of 

cor triatriatum sinistrum. Selective coronary angiography 

revealed a severe ostioproximal stenosis of the left anterior 

descending artery of up to 99%. 

grafting (CABG), during which the anastomosis of the left 

internal mammary artery to the left anterior descending artery 

and the removal of the membrane was performed without 

complications (Figure 5). The patient was discharged on the 

6th postoperative day. 

Figure 2. In transesophageal echocardiography, mid-transesophageal view 

demonstrates the dividing membrane in the left atrial cavity with a small 

orifice (11 mm) (arrow) 

LA, Left atrium; AO, Aorta 

Figure 3. In transesophageal echocardiography, mid-transesophageal aortic 

valve long-axis view demonstrates an abnormal membrane across the patient’s 

left atrium (arrow) 

LV, Left ventricle; LA, Left atrium; AAO, Ascending aorta 

Figure 1. Transthoracic three-D echocardiogram showing the membrane in 

the left atrial cavity (arrow) 

LV, Left ventricle; LA, Left atrium 

The patient underwent on-pump coronary artery bypass 

Discussion 

Cor triatriatum sinistrum is a rare congenital cardiac 

anomaly and is responsible for 0.1-0.4% of all congenital 

cardiac malformations, without any known associated 

genetic abnormalities.¹ , ² It has gender predilection with 

86

Incidental Finding of Cor Triatriatum Sinistrum in a Middle-Aged Man ... 

Figure 4. Doppler flow imaging across the membrane orifice (transesophageal 

echocardiography (view) 

Figure 5. Macroscopic view of the removed left atrial membrane from the 

pulmonic veins aspect (5.5 × 4 cm) 

slight male predominance involvement (1.4:1) and is 

associated with other cardiac defects in up to 50% of cases. 

Examples of associated cardiac defects include atrial septal 

defect, persistent left superior vena cava, partial anomalous 

pulmonary venous connections, ventricular septal defect, 

and more complex cardiac lesions such as the tetralogy of 

Fallot, atrioventricular septal defect and double outlet right 

ventricle. 

In its most common form of cor triatriatum sinistrum, the 

left atrium is divided into proximal and distal chambers. 

Both chambers are separated by a diaphragm with one or 

more restrictive ostia, with the pulmonary veins draining into 

the proximal chamber. The location of the atrial appendage 

is a key landmark in this congenital malformation: In cor 

triatriatum, the atrial appendage is invariably connected with 

the lower chamber, which is below the membrane.³ 

When the atrial septal defect exists between the left atrial 


accessory chamber and the right atrium, the patients refer 

to hospital with symptoms of associated elevated pulmonary 

venous and arterial pressures because blood is shunted from 

left to right 3, 4 In our case, the patient only had a history of 

dyspnea on exertion and there was no evidence of intracardiac 

shunt. 

The primary concern with cor triatriatum sinistrum is 

the potential for the left ventricle inlet obstruction, leading 

to mitral stenosis physiology. It is deserving of note that 

the pulmonary venous inflow can be compromised, albeit 

rarely, 5 but there was no evidence of the left ventricle inlet 

obstruction in our patient. The chest radiograph usually 

shows increased vascular markings, and a cardiac murmur 

is frequently noted. Be that as it may, with cor triatriatum 

sinistrum, the apical diastolic rumble of mitral stenosis 

is generally absent. Some patients with cor triatriatum 

sinistrum may remain asymptomatic, whereas others may 

have late onset of symptoms, which is possibly related to the 

fibrosis and calcification of the membrane with associated 

atrial fibrillation or mitral regurgitation. 6 

ECG findings are non-specific, but may reveal right-axis 

deviation with right atrial and right ventricular hypertrophy 

and atrial arrhythmia in some patients. Echocardiography is 

often sufficient for the diagnosis and TEE is the diagnostic 

modality of choice. Three-D echocardiography is also a new 

modality for the diagnosis and enjoys high accuracy. 7-10 The 

only treatment is surgical correction, and the majority of 

postoperative deaths occur in the first 30 days. In the early 

surgical series, the mortality was as high as 15-20% but 

more recently the rates have reached as low as 2%. 11, 12 Longterm 

results are excellent, with survival rates of 80-90% in 

patients surviving surgery. 11-14 Our patient also underwent a 

successful surgical operation and he was well at the firstmonth 

follow-up. 

References 

1. Niwayama G. Cor triatriatum. Am Heart J 1960;59:291-317. 

2. Jorgensen CR, Ferlic RM, Varco RL, Lillehei CW, Eliot RS. Cor 

triatriatum. Review of the surgical aspects with a follow-up report 

on the first patient successfully treated with surgery. Circulation 

1967;36:101-107. 

3. Marín-García J, Tandon R, Lucas RV Jr, Edwards JE. Cor 

triatriatum: study of 20 cases. Am J Cardiol 1975;35:59-66. 

4. Oglietti J, Cooley DA, Izquierdo JP, Ventemiglia R, Muasher I, 

Hallman GL, Reul GJ, Jr. Cor triatriatum: operative results in 25 

patients. Ann Thorac Surg 1983;35:415-420. 

5. Melnick AH, Brzezinski M, Mark JB. Incidental cor triatriatum 

sinister during coronary artery bypass surgery. Anesth Analg 

2005;101:637-638. 

6. Chen Q, Guhathakurta S, Vadalapali G, Nalladaru Z, Easthope RN, 

Sharma AK. Cor triatriatum in adults: three new cases and a brief 

review. Tex Heart Inst J 1999;26:206-210. 

7. Schluter M, Langenstein BA, Their W. Transesophageal twodimensional 

echocardiography in the diagnosis of cor triatriatum 

in the adult. J Am Coll Cardiol 1983;2:1011-1015. 

8. Tantibhedhyangkul W, Godoy I, Karp R, Lang RM. Cor triatriatum 



Afsoon Fazlinezhad et al. 

in a 70-year- old woman: role of transesophageal echocardiography 

and dynamic three-dimensional echocardiography in diagnostic 

assessment. J Am Soc Echocardiogr 1998;11:837-840. 

9. Jeong JW, Tei C, Chang KS, Tanaka N, Lee SK, Toda H. A case 

of Cor triatriatum in a eighty-year old man: transesophageal 

echocardiographic observation of multiple defects. J Am Soc 

Echocardiogr 1997;10:185-188. 

10. Wang XC, Deng YB, Nanda NC, Deng J, Miller AP, Xie MX. 

Live three-dimensional echocardiography: imaging principles and 

clinical application. Echocardiography 2003;20:593-604. 

11. Rodefeld MD, Brown JW, Heimansohn DA, King H, Girod DA, 

Hurwitz RA, Caldwell RL. Cor triatriatum: clinical presentation 

and surgical results in 12 patients. Ann Thorac Surg 1990;50:562- 

512. 

12. van Son JA, Danielson GK, Schaff HV, Puga FJ, Seward JB, Hagler 

DJ, Mair DD. Cor triatriatum: diagnosis, operative approach, and 

late results. Mayo Clin Proc 1993;68:854-859. 

13. Ozkökeli M, Kayacioğlu I, Sensöz Y, Uslu N, Kanca A. Cor 

triatriatum sinistrum in adults: surgical treatment of two cases. 

Anadolu Kardiyol Derg 2007;7:200-201. 

14. Horowitz M, Zager W, Bilsker M, Perryman RA, Lowery MH. Cor 

triatriatum in adults. Am Heart J 1993;126:472-474. 

88


Case Report 

Segmented Coronary Artery Aneurysms and Kawasaki 

Disease 

Mohammad Yoosef Aarabi Moghadam, MD, Hojat Mortazaeian, MD, Mehdi 

Ghaderian, MD * , Hamid Reza Ghaemi, MD 

Shaheed Rajaei Cardiovascular, Medical and Research Center, Tehran University of Medical Sciences, 

Tehran, Iran 

Received 15 July 2010; Accepted 23 February 2011 

Abstract 

Kawasaki disease (KD) is an acute vasculitis syndrome of unknown etiology. It occurs in infants and young children, 

affecting mainly small and medium-sized arteries, particularly the coronary arteries. Generalized microvasculitis occurs in 

the first 10 days, and the inflammation persists in the walls of medium and small arteries, especially the coronary arteries, 

and changes to coronary artery aneurysms. 

We report the case of a 10-month-old girl referred to our center three months after the onset of disease due to the aneurysms 

of the coronary arteries. During the acute phase of her illness, she received 2 gr/kg intravenous gamma globulin; and after 

her referral to us, the patient was treated by antiaggregant doses of acetylsalicylic acid (ASA) (5 mg/kg) and Warfarin (1 mg/ 

daily). At three months’ follow-up, the aneurysms still persisted in the echocardiogram. 


This paper should be cited as: Aarabi Moghadam MY, Mortazaeian H, Ghaderian M, Ghaemi HR. Segmented Coronary Artery 

Aneurysms and Kawasaki Disease. J Teh Univ Heart Ctr 2011;6(2):89-91. 

Keywords: Mucocutaneous lymph node syndrome • Coronary aneurysm • Child 

Introduction 

Kawasaki disease (KD), first described in Japan in 1967 

by Kawasaki, is an acute vasculitis syndrome of unknown 

etiology occurring in infants and young children and affecting 

mainly small and medium-sized arteries, particularly the 

coronary arteries. Eighty percent of the patients are younger 

than 5 years of age and boys are more susceptible than girls 

with a ratio of approximately 1.5:1. 1 The disease occurs 

most frequently in winter and spring. Young infants have the 

highest rate of coronary artery aneurysm formation and often 

exhibit incomplete clinical presentations. 1 Giant coronary 

artery aneurysms (internal diameters > 8mm) are seen in 

0.5% to 1% of adequately treated patients. 2, 3 Incomplete 

cases are most frequent in infants, who unfortunately also 

have the highest likelihood of developing coronary disease. 4 

Case Report 

A 10-month-old girl referred to our center three months 

after the onset of acute disease (her parents described an 

acute phase with a fever of 10 days’ duration). During the 

acute phase of her illness, she had a polymorphous exanthema 

* 

Corresponding Author: Mehdi Ghaderian, Assistant Professor of Pediatric Cardiology, Department of Pediatric Cardiology, Jundishapor University 

of Medical Sciences, Golestan Medical, Educational and Research center, Ahwaz, Iran. 6135733118. Tel: +98 61 13743063. Fax: +98 61 13743063. E-mail: 

ghader_45@yahoo.com. 



Mohammad Yoosef Aarabi Moghadam et al. 

with perianal desquamation, a bilateral bulbar conjunctival 

injection, and changes in lips and oral cavity mucosa. She 

received 2 gr/kg intravenous gamma globulin (IVIG); and 

once more, the IVIG infusion caused a persistent fever. In 

follow-up by echocardiography, she had aneurysms of the 

coronary arteries and was therefore referred to our center. 

Echocardiographic examination demonstrated multiple 

aneurysms and diffuse dilatation of the coronary arteries 

(Figure 1). 

Figure 3. Segmented aneurysms in the right coronary artrey (RCA) and dilatation 

in the left coronary artery (LCA) in angiogram (arrows) 

Figure1. Short-axis parasternal echocardiography demonstrating diffuse 

dilatation of the coronary arteries (arrows) 

LCA, Left coronary artery; RCA, Right coronary artery 

No impairment of the left ventricular function was found. 

The standard twelve-lead electrocardiogram showed no 

ischemia or dysrhythmias. The coronary angiograms showed 

diffuse segmented aneurysms (resembling beads on a string) 

of the right coronary artery and left anterior descending artery 

from the ostium to the distal segment (Figures 2 & 3). 

Figure 2. Segmented aneurysms of the left coronary artery (LCA) and right 

coronary artery (RCA) in angiogram (arrows) 

The patient was treated by antiaggregant doses of ASA 

(5 mg/kg) and Warfarin (1 mg/daily). At this point, she was 

followed up via echocardiography. At three months’ followup, 

the aneurysms still persisted in the echocardiogram 

without any new complications such as thrombosis, 

ventricular dysfunction, and myocardial infarction. 

Discussion 

KD is an acute febrile vasculitis of unknown etiology, 

although an infectious or toxic triggering agent is suspected 

by some authors. Its incidence presents regional variations 

that oscillate between 108 in 100,000 children younger than 

5 years of age in Japan and 10 in 100,000 children younger 

than 5 years old in the United States. 5 The acute phase of 

KD usually starts with upper respiratory or gastrointestinal 

prodromal symptoms. It is followed by an abrupt onset 

of high fever, accompanied by skin rash, conjunctival 

injection, reddening and fissuring of lips, erythema of the 

buccal mucosa, strawberry tongue, nonsuppurative cervical 

lymphadenitis, and erythema and edema of the hands and 

feet. 1 ASA and IVIG should be started within 10 days from 

fever onset in order to prevent coronary involvement. 

Overall, 2%-6% of children with KD treated with IVIG 

develop coronary artery disease; it tends to increase to 20%- 

30% in patients who do not receive IVIG. Giant coronary 

artery aneurysms are seen in 0.5% to 1% of adequately 

treated patients. Unfortunately, if the diagnosis is not 

established and treatment is not instituted, some patients 

may suffer sudden death secondary to myocardial infarction 

or coronary aneurysm rupture, or may develop serious 

asymptomatic coronary disease that is unrecognized until 

90

Segmented Coronary Artery Aneurysms and Kawasaki Disease 


the symptoms of myocardial ischemia develop later in life. 4 

The prevalence of coronary aneurysms is higher in infants 

less than 12 months old. Shulman et al. 6 reported that about 

50% of coronary abnormalities regress within 5 years. At 

three months’ follow-up via echocardiography, our patient’s 

aneurysms were still persistent in size. 

References 

1. Takahashi M, Newburger JW. Kawasaki disease (mucocutaneous 

lymph node syndrome). In: Allen HD, Driscoll DJ, Shaddy RE, 

Feltes TF, eds. Moss and Adam’s Heart Disease in Infants, Children 

and Adolescents: Including the Fetus and Young Adults. 7th ed. 

New York: Lippincott Williams & Wilkins; 2008. p. 1243-1256. 

2. Moura C, Costa P, Silva JC. Giant coronary aneurysms in Kawasaki 

disease. Pediatr Cardiol 2008;29:230-231. 

3. Aarabi Moghadam MY, Mearji M, Sayadpoor K. Study of cardiac 

involvement prevalence in 61 pediatric case of Kawasaki disease. 

IJMS 2004;11-extra.1:361-366. 

4. Moreno N, Méndez-Echevarría A, de Inocencio J, Del Castillo 

F, Baquero-Artigao F, García-Miguel MJ, de José MI, Aracil J. 

Coronary involvement in infants with Kawasaki disease treated 

with intravenous gamma-globulin. Pediatr Cardiol 2008;29:31-35. 

5. Shulman ST, McAuley JB, Pachman LM, Miller ML, Ruschhaupt 

DG. Risk of coronary abnormalities due to Kawasaki disease 

in urban area with small Asian population. Am J Dis Child 

1987;141:420-425. 



Case Report 

Traumatic Left Anterior Descending Coronary Artery- 

Right Ventricle Fistula: A Case Report 

Mohammad Ali Sheikhi, MD * , Mehdi Asgari, MD, Mehdi Dehghani Firouzabadi, 

MD, Mohammad Reza Zeraati, MD, Alireza Rezaee, MD 

Abstract 

Golestan Hospital, Jondishapour University of Medical Sciences, Ahvaz, Iran. 

Received 16 May 2009; Accepted 28 October 2010 

Traumatic coronary artery-cameral fistulas (TCAF) are rare and may present secondary to penetrating injuries (80%) 

or iatrogenic traumas. Early operative intervention remains the recommended treatment modality for accidental traumatic 

coronary artery fistulas. We report the case of a 17-year-old man who presented with left anterior descending coronary 

artery-right ventricle fistula following penetrating cardiac trauma, which was successfully repaired surgically. 


This paper should be cited as: Sheikhi MA, Asgari M, Dehghani Firouzabadi M, Zeraati MR, Rezaee AR. Traumatic Left Anterior 

Descending Coronary Artery-Right Ventricle Fistula: A Case Report. J Teh Univ Heart Ctr 2011;6(2):92-94. 

Keywords: Wounds, stab • Coronary vessels • Fistula 

Introduction 

Traumatic cardiac penetration is highly lethal, with 

case fatality rates of 70-80%. Patients that are profoundly 

unstable benefit from emergency thoracotomy with ongoing 

aggressive resuscitation. Postoperative deterioration may 

be due to bleeding or post-ischemic cardiac myocardial 

dysfunction. 

Residual and delayed sequelae include postpericardiotomy 

syndrome, fistulas, valvular dysfunction, ventricular 

aneurysms, and pseudoaneurysms. 1 Traumatic coronary 

artery-cameral fistulas (TCAF) are uncommon sequelae of 

trauma that require early surgical intervention to prevent 

complications. 2 Although the left coronary artery is the 

most frequently injured vessel of the heart, traumatic fistulas 

appear more often in the right coronary vessels, as the initial 

injury to the left coronary artery usually results in early death 

prior to hospitalization. 3 

We report the case of a patient with left anterior descending 

(LAD) artery to right atrium fistula following cardiac 

penetrating trauma. 

Case Report 

A 17-year-old man presented to the emergency room with 

a stab wound to the heart about 45 minutes prior to arrival. 

At arrival, he was in a shock state and was pale, dyspnic, and 

agitated with blood pressure of 80/40 mmHg, heart rate of 130 

beat/min, and respiration rate of 30/min. There was a 4-5 cm 

laceration located at the level of the 3 rd and 4 th ribs in the left 

midclavicular line with active bleeding. He was transferred 

to the operating room immediately while his bleeding was 

controlled by finger pressure and initial resuscitation was 

administered. Anterolateral thoracotomy and repair of the left 

ventricular rupture at the line of the LAD were performed, but 

* 

Corresponding Author: Mohammad Ali Sheikhi, Assistance Professor of Cardiac Surgery, Golestan Hospital, Jondishapour University Ahvaz Iran. 

Tel: +98 91 68013916. Fax: +986113743076. E-mail: sheikh.ma@yahoo.com. 

92

Traumatic Left Anterior Descending Coronary Artery-Right Ventricle Fistula 

the patient suffered dyspnea two hours postoperatively and his 

electrocardiography (ECG) showed ST-T segment elevation 

in the pericardial leads and ST-T segment depression in the 

inferior leads. Transesophageal echocardiography revealed 

severe left ventricular hypokinesia and apical akinesia with a 

left ventricular ejection fraction of 40% and possibility of the 

LAD fistula. Emergency coronary angiography, conducted 

approximately twelve hours postoperatively, showed an 

LAD cut-off at mid part with poor distal run-off and fistula 

of the LAD to the right ventricle (Figures 1). 

Figure 1. Left anterior descending cut-off at mid part with poor distal runoff 

and fistula of the left anterior descending to the right ventricle (arrow) 

LAD, Left anterior descending 

On post-admission day 7, the patient underwent reoperation, 

during which he was placed on cardiopulmonary bypass and 

high-potassium blood cardioplegia was administered. The 

fistula of the LAD to the right ventricle was repaired with 

Prolene 5-0 and the left interior mammary artery was grafted 

to the LAD, distal to the site of the suture ligation of the 

LAD fistula. 

Twenty months later, the patient was in healthy condition. 

Discussion 

Coronary arteriovenous fistulas were first described by 

Krause in 1865. 4 They commonly have a congenital origin 

but can be acquired as complications of surgical procedures 

and traumas. The venous side of the coronary arteriovenous 

fistula can be the coronary sinus, the great cardiac vein, the 

right atrium, or the right ventricle. 5 

Most of the reported cases of accidental traumatic coronary 

artery fistulas were diagnosed several months to years after 


the initial operation when there was morbidity secondary to 

the fistula such as congestive heart failure and pulmonary 

hypertension. Our case was diagnosed early postoperatively 

and underwent reoperation on post-admission day 7. 

Early intervention in TCAF prevents the late complications 

of high flow left-to-right shunting, including the development 

of pulmonary artery hypertension and congestive heart 

failure. 2 Shimabukuro et al. reported the case of a patient with 

cardiac penetrating trauma who presented with congestive 

heart failure and tricuspid regurgitation due to coronary 

arteriovenous fistula 8 years after trauma. They suggested 

that early surgical repair be undertaken in cases of traumatic 

coronary artery fistula, even if the shunt is minimal and 

early symptoms are mild. 6 Bernard Maitre et al. reported the 

unusual case of a patient with left ventricular aneurysm and 

coronary-pulmonary artery fistula detected 23 years after a 

thoracic wound; the patient presented with severe hemoptysis 

and anemia. 1 Reubendra and associates reported the case of a 

patient with traumatic LAD-to-pulmonary artery fistula that 

developed delayed pericardial tamponade and underwent 

emergency intervention; they believe that survival is not 

unlikely with fistulas occurring in the mid-LAD to right 

ventricle, as indicated by the significant number of reported 

cases. Proximal LAD fistulas are probably more likely to 

result in a fatal injury, but early repair seems indicated given 

the life-threatening sequelae such as delayed pericardial 

tamponade. 7 

Depending on whether the drainage is into the left or right 

heart, coronary artery fistulas are classified into two major 

types. Akhras et al. reported a right coronary artery-right atrial 

fistula about 40 years after shrapnel injury. 8 Alberto Rangel 

and associates presented the case of a 17-year-old man who 

sustained a knife chest wound and secondarily developed a 

traumatic coronary arteriovenous fistula communicating the 

left main coronary artery to the pulmonary artery, associated 

with pulmonary valvular insufficiency and endocarditis. 9 

Survivors of traumatic coronary artery fistulas have an 

excellent prognosis after successful closure of the fistula. 10 

We suggest that patients with traumatic coronary artery 

fistulas be considered for elective surgical repair to prevent 

the development of complications. Operative repair can be 

accomplished safely with excellent long-term outcome. 

Conclusion 

Most patients with traumatic coronary artery fistulas should 

undergo early surgical intervention to prevent the sequelae 

of a left-to-right shunt since survivors of traumatic coronary 

artery fistulas have an excellent prognosis after a successful 

closure of the fistula. 



Mohammad Ali Sheikhi et al. 

References 

1. Austin SM, Applefeld MM, Turney SZ, Mech KF. Traumatic left 

anterior descending coronary artery to right ventricle fisula. South 

Med J 1977;70:581-584. 

2. Hancock Friesen C, Howlett JG, Ross DB. Traumatic coronary 

artery fistula management. Ann Thorac Surg 2000;69:1973-1982. 

3. Reyes LH, Mattox LK, Gaasch WH, Espada R, Beall AC, Jr. 

Traumatic coronary artery-right heart fistula. Report of a case and 

review of the literature. J Thorac Cardiovasc Surg 1975;70:52-56. 

4. Maitre B, Jouveshomme S, Isnard R, Riquet M, Pavie A, Derenne 

JP. Traumatic coronary-pulmonary artery fistula, 23 years after a 

stab wound. Ann Thorac Surg 2000;70:1399-1400. 

5. Martin R, Mitchell A, Dhalla N. Late pericardial tamponade 

and coronary arteriovenous fistula after trauma. Br Heart J 

1986;55:216-218. 

6. Shimabukuro M, Shinzato T, Yoshida H, Nagamine F, Takasu N, 

Koja K. Late complications in traumatic coronary artery fistula: 

report of a case requiring surgical repair after 8 years. Cardiology 

1996;87:86-89. 

7. Jeganathan R, Irwin G, Johnston PW, Jones JM. Traumatic left 

anterior descending artery-to-pulmonary artery fistula with delayed 

pericardial tamponade. Ann Thorac Surg 2007;84:276-278. 

8. Akhras F, Daly K, Gishen P, Keates J, Jackson G. Traumatic right 

coronary artery--right atrial fistula. Eur Heart J 1983;4:815-818. 

9. Rangel A, Badui E, Verduzco C, Valdespino A, Enciso R. Traumatic 

coronary arteriovenous fistula communicating the left main 

coronary artery to pulmonary artery, associated with pulmonary 

valvular insufficiency and endocarditis: case report. Angiology 

1990;4:156-160. 

10. Lowe JE, Adams DH, Cummings RG, Wesly RL, Phillips HR. The 

natural history and recommended management of patients with 

traumatic coronary artery fistulas. Ann Thorac Surg 1983;36:295- 

305. 

94


Letter to the Editor 

Percutaneous Revascularization 

of Patients with History of 

Coronary Artery Bypass 

Grafting 

Special thanks are due to Dr. Fatemeh Behboudi et al. 

for their invaluable work on percutaneous intervention on 

grafted veins as well as native coronary arteries in patients 

with previous history of coronary artery bypass graft )CABG) 

surgery. 1 They report 71 patients with a history of CABG, 

in whom percutaneous coronary intervention (PCI) was 

performed on native vessels in 60%, on grafted vessels in 

32%, and on both in the remaining 8%. 

In the modern era of cardiovascular medicine, CABG 

and PCI are not rivals but could be complementary to each 

other. With the increasing age of patients with a history of 

CABG, atherosclerotic changes progress in their native as 

well as grafted vessels. Within 10 years after CABG, nearly 

half of saphenous vein grafts (SVGs) fail or demonstrate 

significant atherosclerotic disease and the patients become 

symptomatic. 2 Atherosclerotic plaques in SVGs are always 

complex and friable and may be associated with thrombus. 3 

The first approach to the symptomatic stable post-CABG 

patient is optimizing medical treatment as well as assessing 

the amount of myocardium in jeopardy and localizing the 

ischemia by non-invasive tests such as imaging modalities. 

In case of medical treatment failure or high-risk non-invasive 

test results, or if the presentation of the patient is acute 

coronary syndrome, coronary angiography may be indicated 

and revascularization is on the table. Redo CABG could be 

an option, but there are some obstacles. Higher mortality 

and morbidity has been reported compared with first CABG, 

especially in subjects with advanced age and with comorbid 

states. 4 Sternotomy could be a potential hazard for the 

grafted internal mammary artery. The second approach is 

PCI on either native coronary arteries or grafted vessels or 

both whenever feasible and is indicated based on the area of 

the ischemia. PCI is often the preferred treatment option in 

this population since reoperation imposes substantial risk on 

these subjects. 

The study conducted by Dr. Behboudi and her colleagues 

is a report on in-hospital and mid-term outcome of PCI on 

patients with a previous history of CABG. The favorable 

outcome of the subjects in this study encourages the 

cardiologists to perform PCI on this group of patients. 

Whether the native vessel or the SVG is preferable for PCI 

is not answered in this survey. The target vessel for PCI in 

post-CABG patients is sometimes a matter of debate, and 

the selection of the native vessel or SVG with significant 

stenosis for intervention is not always a simple decision. A 

comparison of the major adverse cardiac events (MACE) 

rate, procedural complications, and outcome between the 

two groups can help solve this problem. 

The percutaneous treatment of the SVG has been a matter 

of interest for many years, and there is a large body of data on 

this procedure. The SVG could be a target because of lesser 

tortuosity, less calcification, and larger diameter compared 

with native vessels. The mechanisms of stenosis in the SVG 

are somehow different from those in native coronary arteries. 3 

Native coronary artery and SVG atherosclerosis should be 

considered different diseases. Atherosclerotic plaques in the 

graft are more diffuse, friable, soft, and lipid-rich. These 

characteristics render SVG lesions prone to fragmentation 

and distal embolization during PCI. 5 The incidence of no 

reflow and rate of periprocedural myocardial infarction 

are higher in SVG angioplasty, owing in large part to the 

embolization of the abundant and friable atherosclerotic 

debris in diseased SVGs. 3, 6 The use of embolic protection 

devices (EPDs) has been demonstrated to reduce the 

major adverse cardiac events rate as well as no reflow in 

SVG angioplasty 7 and these devices are recommended in 

guidelines whenever technically feasible. 8 Despite these 

supporting data, EPDs are used only in 22% of patients in 

the United States. 9 

In this study, Dr. Behboudi et al. mention that PCI on 

post-CABG patients is feasible and safe. A challenge is that 

which vessel is better for intervention ,the native vessel or the 

SVG Was there any difference in the MACE rate between 

the group who underwent PCI on their native coronaries 

and those with intervention on their SVGs It seems that the 

sample size was not sufficient for such an analysis. Provision 

of information on the no-reflow rate in the SVG group and 

utilization rate of EPDs would be helpful. There is room 

for investigation about the procedural time, radiation dose, 

and amount of contrast injection in SVG intervention and 

a comparison with PCI on native vessels in post-CABG 

patients. 

We will encounter more symptomatic post-CABG patients 

in the future. More PCI procedures will be carried out on 

these patients either on their native or their grafted vessels. 

More data are needed to help select the best target vessel 

to obtain maximal efficacy and minimal risk. Sometimes 

we have to open as much vessel as we can, especially when 

the patient remains symptomatic despite opening one target 

vessel. 

The important role of optimal medical treatment should 



Fatemeh Behboudi et al. 

not be forgotten. Preventive efforts to halt the progression of 

atherosclerotic changes in grafted veins and native coronary 

arteries perhaps are the better way ;be that as it may ,the 

impact of risk factor modification and changing life style on 

this issue needs to be confirmed with larger scale clinical 

trials. 

References 

1. Behboudi F, Vakili H, Hashemi SR. Immediate results and sixmonth 

clinical outcome after percutaneous coronary intervention 

in patients with prior coronary artery bypass surgery. J Teh Univ 

Heart Ctr 2011;6:31-36. 

2. Goldman S, Zadian K, Moritz T, Ovitt T, Sethi G, Copeland 

JG. Long term patency of saphenous vein and internal mamary 

artery grafts after coronary artery bypass surgery; results from a 

department of veterans affairs cooperative study. J Am Coll Cardilo 

2004;44:2149-2156. 

3. Kereiakes DJ, Turco MA, Breall J. A novel filter-based distal 

embolic protection device for percutaneous intervention of 

saphenous vein graft lesions. J Am Coll Cardiol 2008;1:248-257. 

4. Fitzgibbon GM, Kafka HP, Leach AJ. Coronary bypass graft 

fate and patient outcome: angiographic follow-up of 5,065 grafts 

related to survival and reoperation in 1,388. J Am Coll Cardiol 

1996;28:616-626. 

5. Roffi M, Mukherjee D. Current role of emboli protection devices 

in percutaneous coronary and vascular interventions. Am Heart J 

2009;157:263-270. 

6. Kirtane AJ, Heyman ER. Correlates of adverse events during 

saphenous vein graft intervention with distal embolic protection, a 

PRIDE substudy. J Am Coll Cardiol 2008;1:186-191. 

7. Baim DS, Wahr D, George B, Leon MB, Greenberg J, Cutlip 

DE, Kaya U, Popma JJ, Ho KK, Kuntz RE; Saphenous vein 

graft Angioplasty Free of Emboli Randomized (SAFER) Trial 

Investigators. Randomized trial of a distal embolic protection 

device during percutaneous intervention of saphenous vein aortocoronary 

bypass grafts. Circulation 2002;105:1285-1290. 

8. Smith SC, Jr, Feldman TE, Hirshfeld JW, Jr, Jacobs AK, Kern MJ, 

King SB, 3rd, Morrison DA, O'Neil WW, Schaff HV, Whitlow 

PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon 

DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, 

Ornato JP, Page RL, Riegel B; American College of Cardiology/ 

American Heart Association Task Force on Practice Guidelines; 

ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines 

for Percutaneous Coronary Intervention. ACC/AHA/SCAI 2005 

guideline update for percutaneous coronary intervention: a report 

of the American College of Cardiology/American Heart Association 

Task Force on Practice Guidelines. Circulation 2006;113:e166-286. 

9. Mehta SK, Frutkin AD, Milford-Beland S, Klein LW, Shaw RE, 

Weintraub WS, Krone RJ, Anderson HV, Kutcher MA, Marso SP; 

American College of Cardiology-National Cardiovascular Data 

Registry. Utilization of distal embolic protection in saphenous vein 

graft interventions. Am J Cardiol 2007;100:1114-1118. 

Seyed Kianoosh Hoseini, 

Assistant Professor of Cardiology, 

Tehran University of Medical Sciences, 

Tehran Heart Center, 

Karegar Ave, 

Tehran, 

Iran. 

1411713138. 

Tel: + 98 21 88029702. 

Fax: + 98 21 88029731. 

E-mail: kianhoseini@tums.ac.ir. 

Percutaneous Revascularization 

of Patients with History of 

Coronary Bypass Graft: Reply 

First of all, allow me to thank you very much for your 

interest in our study. 1 

Our study was performed in a single center with a small 

group of patients, which may have created some bias in 

the prediction of adverse outcomes. In addition, the small 

size of the study population precluded a comparison of 

the outcomes between those who underwent percutaneous 

coronary intervention )PCI) on native coronaries and those 

who received intervention on saphenous vein grafts )SVGs). 

Nevertheless, the results of our study showed that PCI 

on native coronaries is more desirable than PCI on SVGs 

because many of our major adverse cardiac event (MACE) 

cases were in the SVG group. 

With respect to the next question, only 5% of our SVG group 

cases had no distal protection devices ,and there was one case 

of non ST-elevation myocardial infarction )NSTEMI) due to 

the no-reflow phenomenon after stenting a SVG on the optus 

marginal (OM) artery and no distal protection devices were 

used. Finally, we had one case of ST-elevation myocardial 

infarction (STEMI) due to the distal embolization in the PCI 

of the SVG on the OM artery despite using a distal protection 

device; however, no no-reflow phenomenon was observed in 

the native coronaries group. Studies have shown the consistent 

benefits of embolic protection devices, independent of 

glycoprotein IIb/IIIa antagonist use. Embolic protection has 

been established as the standard of care for SVG stenting, 

with a favorable cost-benefit profile. 2, 3 Embolic protection 

devices reduce the secondary phenomena of no-reflow and 

end organ infarction. 4-7 

We hope that our explanations will help the esteemed 

readers to better understand the views mentioned. 

References 

1. Behboudi F, Vakili H, Hashemi SR, Hekmat M, Safi M, Namazi 

MH. Immediate results and six-month clinical outcome after 

percutaneous coronary intervention in patients with prior coronary 

artery bypass surgery. J Teh Univ Heart Ctr 2011;6:31-36. 

2. Baim DS, Wahr D, George B, Leon MB, Greenberg J, Cutlip 

DE, Kaya U, Popma JJ, Ho KK, Kuntz RE; Saphenous vein 

graft Angioplasty Free of Emboli Randomized (SAFER) Trial 

96

Percutaneous Revascularization of Patients with History of Coronary Artery ... 


Investigators. Randomized trial of a distal embolic protection 

device during percutaneous intervention of saphenous vein aortocoronary 

bypass grafts. Circulation 2002;105:1285-1290. 

3. Giugliano GR, Kuntz RE, Popma JJ, Cutlip DE, Baim DS: 

Saphenous vein graft Angioplasty Free of Emboli Randomized 

(SAFER) Trial Investigators. Determinants of 30-day adverse 

events following saphenous vein graft intervention with and 

without a distal occlusion embolic protection device. Am J Cardiol 

2005;95:173-177. 

4. Cohen DJ, Murphy SA, Baim DS, Lavelle TA, Berezin RH, 

Cutlip DE, Ho KK, Kuntz RE; SAFER Trial Investigators. Costeffectiveness 

of distal embolic protection for patients undergoing 

percutaneous intervention of saphenous vein bypass grafts: results 

from the SAFER trial. J Am Coll Cardiol 2004;44:1801-1808. 

5. Carrozza JP. Jr, Mumma M, Breall JA, Fernandez A, Heyman E, 

Metzger C; PRIDE Study Investigators. Randomized evaluation 

of the TriActiv balloon-protection flush and extraction system for 

the treatment of saphenous vein graft disease. J Am Coll Cardiol 

2005;46:1677-1683. 

6. Rogers C, Huynh R, Seifert PA, Chevalier B, Schofer J, Edelman 

ER, Toegel G, Kuchela A, Woupio A, Kuntz RE, Macon ND. 

Embolic protection with filtering or occlusion balloons during 

saphenous vein graft stenting retrieves identical volumes and sizes 

of particulate debris. Circulation 2004;109:1735-1740. 

7. Stone GW, Rogers C, Hermiller J, Feldman R, Hall P, Haber R, 

Masud A, Cambier P, Caputo RP, Turco M, Kovach R, Brodie 

B, Herrmann HC, Kuntz RE, Popma JJ, Ramee S, Cox DA; 

FilterWire EX Randomized Evaluation Investigators. Randomized 

comparison of distal protection with a filter-based catheter and 

a balloon occlusion and aspiration system during percutaneous 

intervention of diseased saphenous vein aorto-coronary bypass 

grafts. Circulation 2003;108:548-553. 

Fatemeh Behboudi, 

Cardiologist, 

Department of Cardiovascular Medicine, 

Shaheed Beheshti University of Medical Sciences, 

Modarres Hospital, 

Tehran, 

Iran. 

199873438. 

Tel: +98 21 22083106. 

Fax: +98 21 22083106. 

Email: dr_h_behbudi@yahoo.co. 



INTERNATIONAL CARDIOVASCULAR SURGERY 

MEETINGS CALENDER (2011-2012) 

Congress Time - Location Address 

Intermediate Cardiac Surgery 

APACVS 30th Annual Winter Educational Meeting 

47th Annual Meeting of The Society of The Thoracic 

Surgeon 

2011 SCMR/Euro CMR Scientific Sessions 

11th Annual International Symposium on Congenital 

Heart Disease 

40th Annual Meeting of the German Society for 

Thoracic and Cardiovascular Surgery 

Annual Meeting of Indian Association of 

Cardiovascular Thoracic Surgeon (57th) 

EACTS Robotic Course (Part II) 

The 3 rd Joint meeting 29th Cardiovascular Surgical 

Symposium 6th Cardiac Surgery Update & 

Progress 

5-6 January 2011 

London 

UK 

28-30 January 2011 

San Diego, CA 

United States 

31 January-02 February 2011 

San Diego, CA 

United States 

03-06 February 2011 

Nice 

France 


FL 

United States 


Stuttgart 

Germany 


Mahabalipuram 

India 


Strasbourg 

France 

26 February-05 March 2011 

Zürs 

Austria 

http://www.rcseng.ac.uk/education/ 

courses/intermediate-cardiac-surgery 

http://www.apacvs.org/documents/PDF/ 

APACVS_Program_San_Diego_2010-.pdf 

http://www.sts.org/sections/ 

annualmeeting/ 

http://www.scmr.org/ 

http://www.allkids.org/conferences 

http://www.gstcvs.org/sections/meetings/ 

index.html 

http://www.ctcon2011.com/conference.htm 

http://www.eacts.org/content/eactsmeetings-courses 

http://www.surgery-zurs.at/ 

98



Re-evolution Summit II: Minimal Access & Hybrid 

Cardiac Surgery With the Cardiovascular Simulation 

Stampede 

The Society of Cardiovascular Anesthesiologists 

(SCA) 16th Annual Update on Cardiopulmonary 

Bypass 

EACTS Right ventricular outflow tract mangement 

from neonates to adults: an interdisciplinary view 

Marbella Aortic Symposium - Disasters In Open and 

Endovascular Aortic Procedures, Learning from 

Complications 

31st Annual 2011 CREF Perfusion Meeting 

cardiothoracic surgery symposium 

EACTS Course “Open and endovascular aortic 

therapy” 

Society for Cardiothoracic Surgery in Great 

Britain and Ireland (SCTS) Annual meeting and 

cardiothoracic forum 2011 

Asia Pacific Heart Valve Forum - Beyond the Basics 

31st Annual Meeting for The International Society 

for Heart and Lung Transplantation (ISHLT) 

AmSECT 49th International Conference 

50 Years of Cardiac Surgery University Hospital 

Zurich 

18th Annual Conference of the Egyptian Society of 

Cardiothoracic Surgery 

Arteriosclerosis, Thrombosis and Vascular Biology 

2011 Scientific Sessions in collaboration with the 

Council on Peripheral Vascular Disease 

Advanced Cardiac Techniques in Surgery (ACTS) 

2011 

Mitral 2011 Conclave 

7th International Conference of the Pediatric 

Mechanical Circulatory Support Systems & 

Cardiopulmonary Perfusion 

03-05 March 2011 

Houston, TX 

United States 

06-11 March 2011 

Whistler, BC 

Canada 

11-12 March 2011 

Palma de Majorca 

Spain 

11-12 March 2011 

Marbella 

Spain 

09-13 March 2011 

Newport beach, CA 

United States 

16-18 March 2011 

Windsor 

UK 

20-22 March 2011 

London 

UK 

31 March-01 April 2011 

Brisbane, Queensland 

Australia 

13-16 April 2011 

San Diego, California 

United States 

13-16 April 2011 

New Orleans, LA 

United States 

15-16 April 2011 

Zurich 

Switzerland 

27-29 April 201 

Alexandria 

Egypt 

28-30 April 2011 

Chicago, IL 

United States 

04-05 May 2011 

New York, NY 

United States 

05-06 2011 May 

New York, NY 

United States 

05-07 May 2011 

Philadelphia 

United States 

cme@tmhs.org 

http://www.scahq.org/sca3/events/2011/ 

cbp/abstracts/ 

http://www.eacts.org/content/eactsmeetings-courses 

http://www.MAS2011.COM 

http://www.amainc.com/cref_ 

cardiothoracic.html 

http://www.eacts.org 

http://meeting.scts.org/ 

http://www.tayloredimages.com.au 

http://www.ishlt.org 

http://www.amsect.org 

http://www.50yearscardiacsurgery.ch/ 

http://escts2011.com 

http://www.americanheart.org/presenter. 

jhtmlidentifier=3057022 

http://www.promedicacme.com 

http://www.aats.org/mitral/index.html 

http://www.hmc.psu.edu/childrens/pedscpb 




AmSECT Perfusion Safety & Best Practices 

in American PerfusionAssociation for Thoracic Surgery's 91st 

Annual Meeting 

MIRA (Minimally Invasive Robotic Association) 6th 

International Congress 

Innovations and Practical Applications in Vascular 

Surgery Special Sessions: Management of Non- 

Healing Wounds 

The 60th International Congress of the European 

Society for Cardiovascular and Endovascular 

Surgery (ESCVS) 

Houston Aortic Symposium: Frontiers in 

Cardiovascular Diseases, The Fourth in the Series 

ASCVTS-ATCSA 2011 Joint Meeting of 19 th ASCVTS 

and 21 st ATCSA 

The international society for minimally invasive 

cardiothoracic surgery (ISMICS) 2011 Annual 

Meeting 

Liverpool Aortic Symposium IV New Frontiers - Biannual 

event 

European Society for Surgical Research (ESSR) 

Annual Scientific Congress 2011 

21st Congress of the World Society of Cardio- 

Thoracic Surgeons 

5th Annual The New Orleans Conference: Practices in 

Cardiac Surgery and Extracorporeal Technologies 

3rd Scientific Meeting of The World Society for 

Pediatric and Congenital Heart Surgery 

6th Biennial Meeting - Joint meeting of the Society 

for heart valve Disease & Heart Valve Society Of 

America 

2011 ISCVID - 11th International Symposium 

on Modern Concepts in Endocarditis and 

Cardiovascular Infections 

Inaugural Meeting Of The Federation Of 

Asian Perfusion Societies - “New Frontiers In 

Cardiovascular Perfusion” 

25th European Association for Cardio-thoracic 

Surgery (EACTS) Annual Meeting 

07-11 May 2011 

Philadelphia 

United States 

11-13 May 2011 

Athens 

Greece 

12-13 May 2011 

New York, NY 

United States 

20-22 May 2011 

Moscow 

Russian 

24-26 Mar 2011 

Houston, TX 

United States 

26-29 May 2011 

Phuket 

Thailand 

08-11 June 2011 

Washington, DC 

United States 

09-10 June 2011 

Liverpool 

United Kingdom 

09-11 June 2011 

Crete 

GREECE 

13-15 June 2011 

Berlin 

Germany 

14-18 June 2011 


United States 

23-26 June 2011 

Istanbul 

Turkey 

25-28 June 2011 

Barcelona 

Spain 

24-26 July 2011 

Queensland 

Australia 

17-18 September 2011 

Singapore 

01-05 October 2011 

Lisbon 

Portugal 

http://www.aats.org/ 

http://www.mirasurgery.org/abstracts/ 

index.php 

http://www.columbiasurgery.org/cme/ 

event_20110512.html 

http://escvs2011.org/escvs/ 

http://www.promedicacme.com/ 

meeting/Houston-Aortic-Symposium- 

Frontiers-in-66.html 

http://www.ascvts-atcsa2011.org/ 

http://www.ismics.org/annualMeeting. 

html 

http://www.lorrainerichardsonl@ 

btinternet.com 

http://www.essr.org/cms/website. 

phpid=/en/essr_home.htm 

http://www.wscts2011.com/ 

http://www.TheNewOrleansConference.com 

http://www.wspchs2011.org/en/ 

http://www.shvd@imperial.ac.uk 

http://www.iscvid2011.com 

http://www.secretariat@ssect. 

http://www.eacts.org/ 

100


INTERNATIONAL CARDIOVASCULAR MEETING 

AND CONGRESSES CALENDER (2011-2012) 

Title Location Start Date End Date 

The international Symposium on Endovascular Therapy, 

ISET 2011 

Miami Beach, FL 

United States 

16 January 2011 


32nd Annual Seminar of The American Academy 

of Cardiovascular Perfusion 

Reno, Nevada 

United States 



Arrhythmias & the Heart 

Kohala Coast 

Hawaii 


3 February 2011 

Cardiovascular Disease Prevention 2011: Ninth Annual 

Comprehensive Symposium 

Coral Gables, Florida 

United States 



Vascular Care 2011 

Truckee, ca 

United States 



36th Annual Cardiovascular Conference at Snowbird 

Snowbird, Utah 

United States 



30th Annual Scientific Meeting of the Belgian Society of 

Cardiology 

Brussels 

BeIgium 



3rd National Conference Chronic Heart Failure and 

Hypertension 2011 

London 

UK 



11th Annual International Symposium on Congenital Heart 

Disease 

St. Petersburg, Florida 

United States 



Bahrain 2011 Pan Arab and European HTN Conference 

Bahrain 



iCON 2011 – International Congress for Endovascular 

Interventions 

Scottsdale, AZ 

United States 



Diagnostic and Interventional Radiology 2011 

2nd national conference 

London 

UK 






Scottsdale Interventional Forum 2011 

Scottsdale, AZ 

United States 



5th Annual Cardiovascular Congress (MECC 2011) 

Kish 

Iran 



10th Genoa Meeting on Hypertension, Diabetes and Renal 

Diseases 

Genoa 

Italy 



CardioRhythm 2011 

Hong Kong 



CRT 2011: Cardiovascular Research Technologies 

Washington, DC 

United State 


1 March 2011 

16th Annual 2011 Cardiology at Cancún-Focus on Clinical 

Cardiology and Prevention 

Cancún 

Mexico 


4 March 2011 

The Future of Genomic Medicine IV 

San Diego, CA 

United States 

3 March 2011 

4 March 2011 

Interventional Cardiology 2011: 26th Annual International 

Symposium 

Snowmass Village, CO 

United States 

13 March 2011 

18 March 2011 

75th Annual Scientific Meeting of the Japanese Circulation 

Society (JCS2011) 

Yokohama 

Japan 

18 March 2011 

20 March 2011 

Heart Attack 2011 /5th Acute Cardiac Care Course 

Cairo 

Egypt 

23 March 2011 

25 March 2011 

XII International Forum for the Evaluation of 

Cardiovascular Care 

Budapest 

Hungary 

24 March 2011 

26 March 2011 

The Houston Aortic Symposium: Frontiers in 

Cardiovascular Diseases, the Fourth in the Series 

Houston, TX 

United States 

24 March 2011 

26 March 2011 

IX National Congress of the Italian Society for 

Cardiovascular Prevention - (SIPREC) 

Genoa 

Italy 

31 March 2011 

02 April 2011 

11th Annual Spring Meeting on Cardiovascular Nursing 

Brussels 

Belgium 

1 April 2011 

2 April 2011 

60th Annual Scientific Session & Expo, ACC i2 Summit 

New Orleans 

United States 

2 April 2011 

2 April 2011 

8th Mediterranean Meeting on Hypertension and 

Atherosclerosis 

Marmaris 

Turkey 

6 April 2011 

10 April 2011 

6th Clinical Update on Cardiac MRI & CT 

Cannes 

France 

8 April 2011 

10 April 2011 

33rd Chairing Cross International Symposium: Vascular & 

Endovascular Consensus Update 

London 

UK 

9 April 2011 

12 April 2011 

EuroPRevent 2011 

Geneva 

Switzerland 

14 April 2011 

16 April 2011 

Angioplasty Summit: Transcatheter Cardiovascular 

Therapeutics Asia Pacific 2011 

Seoul 

Korea 

27 April 2011 

29 April 2011 

Concepts in Contemporary Cardiovascular Medicine 2011 

Houston, TX 

United States 

28 April 2011 

30 April 2011 

SCAI 2011 Scientific Sessions 

Baltimore, MD 

United States 

4 May 2011 

7 May 2011 

102



18th Asian Pacific Congress of Cardiology (APSC 2011) 

Kuala Lumpur 

Malaysia 

5 May 2011 

8 May 2011 

Complex Coronary Complications (C3) Summit, in Conjunction 

with the SCAI 2011 Scientific Sessions 

Baltimore, MD 

United States 

6 May 2011 

6 May 2011 

New Advances in Cardiovascular and Endovascular 

Technologies 

San Juan 

Puerto Rico 

6 May 2011 

7 May 2011 

17th Annual Interventional Cardiology Fellows Course 

Miami Beach, FL 

United States 

8 May 2011 

11 May 2011 

17th Congress of Iranian Heart Association 

Tehran 

Iran 

10 May 2011 

13 May 2011 

42 ND Congress of ANMCO Italian Association of Hospital 

Cardiologists 

Florence 

Italy 

11 May 2011 

14 May 2011 

ICNC10 - Nuclear Cardiology and Cardiac CT 

Amsterdam 

Netherlands 

15 May 2011 

18 May 2011 

EuroPCR 

Paris 

France 

17 May 2011 

20 May 2011 

Heart Failure Congress 2011 

Gothenburg 

Sweden 

21 May 2011 

24 May 2011 

RHYTHM 2011 

Marseille 

France 

27 May 2011 

28 May 2011 

12th Annual New Cardiovascular Horizons 


United States 

1 June 2011 

4 June 2011 

8th Metabolic Syndrome, Type II Diabetes and 

Atherosclerosis Congress 

Marrakesh 

Morocco 

1 June 2011 

5 June 2011 

The 8 th Tunisian and European days of Cardiology 

Practice 

Hammam Sousse 

Tunisia 

9 June 2011 

11 June 2011 

Live Symposium of Complex Coronary & Vascular Cases 

2011 

New York, NY 

United States 

15 June 2011 

18 June 2011 

21st Annual Scientific Meeting of the European Society of 

Hypertension (ESH) 

Milan 

Italy 

17 June 2011 

20 June 2011 

iCi 2011 - Imaging in Cardiovascular Interventions 

Frankfurt 

Germany 

23 June 2011 

25 June 2011 

CSI 2011-Congenital & Structural Interventions 

Frankfurt 

Germany 

23 June 2011 

25 June 2011 

14th Annual Cardiothoracic Update and TEE Board 

Review 

South Carolina 

United States 

23 June 2011 

26 June 2011 

3rd Annual Joint Scientific Meeting of the Heart Valve Society of 

America & Society for Heart Valve Disease 

Barcelona 

Spain 

24 June 2011 

28 June 2011 

EUROPACE, the Meeting of the European Heart Rhythm 

Association (EHRA) 2011 

Madrid 

Spain 

26 June 2011 

29 June 2011 

79th European Atherosclerosis Society Congress (EAS 

2011) 

Gothenburg 

Sweden 

26 June 2011 

29 June 2011 

Complex Cardiovascular Catheter Therapeutics (C3) 

Orlando, FL 

United States 

26 June 2011 

30 June 2011 




Basic Cardiovascular Sciences 2011 Scientific Sessions 


United States 

18 July 2011 

21 July 2011 

59th Annual Scientific Meeting of the Cardiac Society of Australia 

and New Zealand (CSANZ2011) in conjunction with the 35th Annual 

Scientific Meeting of the International Society for Heart Research 

ESC Congress 2011 

New Zealand 

Australia 

Paris 

France 

11 August 2011 




20th EuroChap 2011 European Congress of the International 

Union of Angiology 

Portorose 

Slovenia 

7 September 2011 


CIRSE 2011 

Munich 

Germany 



27th Annual Echocardiography in Pediatric and Adult 

Congenital Heart Disease 

Rochester, MN, 

United States 

9 October 2011 


9th International Congress on Coronary Artery Disease 

Venice 

Italy 



14th British Society for Heart Failure (BSH) Annual 

Autumn Meeting 2011 

London 

UK 

24 November 2011 


Heart, Vessels & Diabetes European Conference 

Athens 



Multidisciplinary European Endovascular Therapy (MEET 

2011) 

Rome 

Italy 

1 December 2011 


EUROECHO 2010 

Copenhagen 

Denmark 



104


Information for Authors 

The first three consecutive issues of "The Journal of Tehran University Heart Center"were published under the title of 

"The Journal of Tehran Heart Center"with ISSN: 1735-5370. From the fourth issue onward, however, the journal has been 

entitled ‘’The Journal of Tehran University Heart Center"with ISSN:1735-8620. 

Scope of the journal 

"The Journal of Tehran University Heart Center" aims to publish the highest quality material, both clinical and scientific, 

on all aspects of Cardiovascular Medicine. It includes articles related to research findings, technical evaluations, and reviews. 

In addition, it provides a forum for the exchange of information on all aspects of Cardiovascular Medicine, including 

educational issues. "The journal of Tehran University Heart Center" is an international, English language, peer reviewed 

journal concerned with Cardiovascular Medicine. It is an official journal of the Cardiovascular Research Center of the Tehran 

University of Medical Sciences (in collaboration with the Iranian Society of Cardiac Surgeons) and is published quarterly. 

Papers submitted to this journal which do not adhere to the Instructions for Authors will be returned for appropriate revision 

to be in line with the Instructions for Authors. They may then be resubmitted. Submission of an article implies that the work 

described has not been published previously (except in the form of an abstract or as part of a published lecture or academic 

thesis), that it is not under consideration for publication elsewhere, that its publication is approved by all Authors and tacitly 

or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published 

elsewhere in the same form, in English or in any other language, without the written consent of the publisher. 

Article Categories 

The Journal of Tehran University Heart Center” accepts the following categories of articles:” 

Guest Editorial 


Clinical and pre-clinical papers based on either normal subjects or patients and the result of cardiovascular pre-clinical 

research will be Considered for publication provided they have an obvious clinical relevance. 

Brief communication 

Case report 


"The Journal of Tehran University Heart Center" publishes a limited number of scholarly, comprehensive reviews whose 

aims are to summarize and critically evaluate research in the field addressed and identify future implications. Reviews should 

not exceed 5000 words. 

Letter to editor 

Letters to the editor must not exceed 500 words and should focus on a specific article published in "The Journal of Tehran 

University Heart Center" within the preceding 12 weeks. No original data may be included. Authors will receive pre-publication 

proofs, and the authors of the article cited invited to reply. 

Submission of manuscripts 

Four double spaced copies on 8 1/2 × 11 in. paper should be sent to: 

Dr. A. Karimi, 

Editor in Chief, 

"The Journal of Tehran University Heart Center", 


North Kargar Street, 



Tehran, Iran. 

1411713138. 

Photocopies or good reproductions of illustrations are acceptable only on the spare copies. Included also should be a set 

of the electronic files of the manuscript on floppy - disk or CD-ROM. For preparation of electronic files, see the instructions 

herein below. 

Also, manuscripts can be submitted electronically via the journal’s website: http://jthc.tums.ac.ir. On-line submission allows 

the manuscript to be handled in electronic forms throughout the review process. 

Review of manuscripts 

All manuscripts correctly submitted to will first be reviewed by the Editors. Some manuscripts will be returned to authors 

at this stage if the paper is deemed inappropriate for publication in “The Journal of Tehran University Heart Center”, if the 

paper does not meet submission requirements, or if the paper is not deemed to have a sufficiently high priority. All papers 

considered suitable by the Editors to progress further in the review process will undergo appropriate peer review and all papers 

provisionally accepted for publication will undergo a detailed statistical review. 

Preparation of manuscripts 

All submitted manuscripts must not exceed 5000 words, including References, Figure Legends and Tables. The number of 

Tables, Figures and References should be appropriate to the manuscript content and should not be excessive. Authors should 

comply with the manuscript formatting and the ethical conventions of the “Uniform Requirements for Manuscripts Submitted 

to Biomedical Journals” issued by the International Committee of Medical Journal Editors ( http://www.icmje.org ). 

Style and spelling 

Authors whose first language is not English are requested to have their manuscripts checked carefully before submission. 

This will help expedite the review process and avoid confusion. Abbreviations of standard SI units of measurement only 

should be used. 

Declaration of Helsinki 

The Authors should state that their study complies with the Declaration of Helsinki that the locally appointed ethics 

committee has approved the research protocol and that informed consent has been obtained from the subjects (or their 

guardians). 

Clinical trials 

Authors should comply with the clinical trial registration statement from the ICMJE. More information can be found at 

www.icmje.org. Clinical trial reports should also comply with the Consolidated Standards of Reporting Trials (CONSORT) 

and include a flow diagram presenting the enrollment, intervention allocation, follow-up, and data analysis with number of 

subjects for each (www.consort-statement.org). Please also refer specifically to the CONSORT Checklist of items to include 

when reporting a randomized clinical trial. 

Section of the manuscripts 

Original articles should be divided into the following sections: (1) Title page, (2) Abstract and Keywords, (3) Introduction, 

(4) Methods, (5) Results, (6) Discussion, (7) Conclusion, (8) Acknowledgements, (9) References, (10) Figure legends, 

(11) Tables, (12) Figures. 

General format 

Prepare your manuscript text using a word processing package. Submissions of text in the form of PDF files are not 

106


permitted. Manuscripts should be double-spaced, including text, tables, legends and references. Number each page. Please 

avoid footnotes; use instead, and as sparingly as possible, parenthesis within brackets. Enter text in the style and order of 

the Journal. Type references in the correct order and style of the journal. Type unjustified, without hyphenation, except for 

compound words. Type headings in the style of the journal. Use the TAB key once for paragraph indents. Where possible use 

Times New Roman for the text font and Symbol for the Greek and special characters. Use the word processing formatting 

features to indicate Bold, Italic, Greek, Maths, Superscript and subscript characters. Clearly identify unusual symbols and 

Greek letters. Differentiate between the letter o and zero, and the letters I and i and the number 1. Mark the approximate 

position of each figure and table. Check the final copy of your paper carefully, as any spelling mistakes and errors may be 

translated into the typeset version. 

Title page 

The title page should include the following: (1) the title, (2) the name (s) of authors and their highest degree ( no more 

than 12 authors are acceptable), (3) the institution (s) where work was performed, (4) institution, and location of all authors, 

(5) the address, telephone number, fax number and e-mail address of the corresponding author. 

Abstract 

All abstracts may not contain more than 250 words and should also be submitted as a separate file. The abstract should be 

formatted with the following heading: (1) Background, (2) Methods, (3) Results, (4) Conclusion. 

A maximum of six Keywords may be submitted. 

Figures 

The review process will not begin until all figures are received. Figures should be limited to the number necessary for 

clarity and must not duplicate data given in tables or in the text. They must be suitable for high quality reproduction and 

should be submitted in the desired final printed size so that reduction can be avoided. Figures should be no larger than 125 

(height)×180 (width) mm (5×7 inches) and should be submitted in a separate file from that of the manuscript. 

Electronic submission of figures 

Figures should be saved in TIFF format at a resolution of at least 300 pixels per inch at the final printed size for colour 

figures and photographs, and 1200 pixels per inch for black and white line drawings. Although some other formats can be 

translated into TIFF format by the publisher, the conversion may alter the tones, resolution and contrast of the image. Digital 

colour art should be submitted in CMYK rather than RGB format, as the printing process requires colours to be separated 

into CMYK and this conversion can alter the intensity and brightness of colours. Therefore authors should be satisfied with 

the colours in CMYK (both on screen and when printed) before submission. Please also keep in mind that colours can appear 

differently on different screens and printers. Failure to follow these guides could result in complications and delays. 

Photographs: Photographs should be of sufficiently high quality with respect to detail, contrast and fineness of grain to 

withstand the inevitable loss of contrast and detail inherent in the printing process. Please indicate the magnification by a rule 

on the photograph. Colour figures: There is a special charge for the inclusion of colour figures. Figure legends: These should 

be on a separate, numbered manuscript sheet grouped under the heading “Legends” on a separate sheet of the manuscript 

after the References. Define all symbols and abbreviations used in the figure. All abbreviations and should be redefined in 

the legend. 

Tables 

Tables should be typed with double spacing, but minimizing redundant space and each should be placed on a separate 

sheet. Tables should be submitted, wherever possible, in portraits, as opposed to landscape, layout. Each Table should be 

numbered in sequence using Arabic numerals. Tables should also have a title above and an explanatory footnote below. All 

abbreviations and should be redefined in the Footnote. 



Acknowledgements 

All sources of funding and support, and substantive contributions of individuals, should be noted in the Acknowledgements, 

positioned before the list of references. 

Reference format 

Number references sequentially and use Arabic number in superscript to cite the reference in the text. All references 

should be compiled at the end of the article in the Vancouver style. Complete information should be given for each reference 

including the title of the article, abbreviated journal title and page numbers. All authors should be listed. Personal communications; 

manuscripts in preparation and other unpublished data should not be cited in the reference list but may be mentioned 

in parentheses in the text. Authors should get permission from the source to cite unpublished data. 

Titles of journals should be abbreviated in accordance with Index Medicus (see list printed annually in the January issue 

of Index Medicus). If a journal is not listed in Index Medicus then its name should be written out in full. 

Article citation example: 

Journal citation example: 1. Schroeder S, Baumbach A, Mahrholdt H. The impact of untreated coronary dissections on the 

acute and long-term outcome after intravascular ultrasound guided PTCA. Eur Heart J 2000;21:137-145. 

Chapter citation example: 2. Nichols WW, O’Rourke MF. Aging, high blood pressure and disease in humans. In: Arnold 

E, ed. McDonald’s Blood Flow in Arteries: Theoretical, Experimental and Clinical Principles. 3rd ed. London/Melbourne/ 

Auckland: Lea and Febiger; 1990. p. 398-420. 

Webpage citation example: 3. Panteghini M. Recommendations on use of biochemical markers in acute coronary syndrome: 

IFCC proposals. eJIFCC 14. 

http://www.ifcc.org/ejifcc/vol14no2/1402062003014n.htm (28 May 2004). Where the date in parenthesis refers to the 

access date. 

Statistics 

All manuscripts selected for publication will be reviewed for the appropriateness and accuracy of the statistical methods 

used and the interpretation of statistical results. All papers submitted should provide in their Methods section a subsection 

detailing the statistical methods, including the specific method used to summarize the data, the methods used to test their 

hypothesis testing and (if any) the level of significance used for hypothesis testing. 

Conflict of interest 

At submission, the editors require authors to disclose any financial association that might pose a conflict of interest in 

connection with the submitted article. All sources of funding for the work should be acknowledged in a footnote on the title 

page and in the Acknowledgements within the manuscript, as should all the institutional affiliations of the authors (including 

corporate appointments). Other kinds of associations, such as consultancies, stock ownership or other equity interest 

or patent-licensing arrangements should be disclosed to the editors in the cover letter at the time of the of submission. If no 

conflict of interest exists, please state this in the cover letter. 

Proofs 

Page proofs will be sent to the corresponding author. Please provide an e-mail address to enable page proofs to be sent 

as PDF files via e-mail. These should be checked thoroughly for any possible changes or typographic errors. Significant 

alterations instigated at this stage by the author will be charged to the author. It is the intention of the Editor to review, correct 

and publish your article as quickly as possible. To achieve this it is important that all of your corrections are returned to 

us in one all- inclusive mail or fax. Subsequent additional corrections will not be possible, so please ensure that your first 

communication is complete. 

108


New Subscription: 

Surname: 

First Name: 

Hospital or Organization: 

Date of subscription: 

Full mail address: 

Subscription Form 


P.O.BOX: Tell: Fax: 

E-mail: 

Continuation of Subscription: 

The annual Subscription and postage rate: 100/000 Rials for Iran and US $ 100 including postage for other countries. 

Please liquidate the total amount of Subscription and postal charges into: 

Bank: Refah Branch Code: 1232 Account: Tehran Heart Center Account Number: 200001.28 

and send the original Bank slip along with Duly completed form of Subscription to the following address: 

ss: 


North Karegar Street, 

Tehran, Iran: 1411713138 

Tel: +98 21 88029720 

Fax: +98 21 88029702 

E-mail: jthc@tums.ac.ir 


New Subscription: 

Surname: 

First Name: 

Hospital or Organization: 

Date of subscription: 

Full mail address: 

Subscription Form 


P.O.BOX: Tell: Fax: 

E-mail: 

Continuation of Subscription: 

The annual Subscription and postage rate: 100/000 Rials for Iran and US $ 100 including postage for other countries. 

Please liquidate the total amount of Subscription and postal charges into: 

Bank: Refah Branch Code: 1232 Account: Tehran Heart Center Account Number: 200001.28 

and send the original Bank slip along with Duly completed form of Subscription to the following address: 

ss: 


North Karegar Street, 

Tehran, Iran: 1411713138 

Tel: +98 21 88029720 

Fax: +98 21 88029702 

E-mail: jthc@tums.ac.ir 

TEHRAN HEART CENTER

Journal of Tehran University Heart Center

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