Background: Percutaneous coronary intervention (PCI) of total chronic coronary occlusions (CTOs) still remains a major challenge in interventional cardiology. There is little knowledge in the literature about differences in CTO-PCI between diabetic and nondiabetic patients in the era of third-generation drug-eluting stents (DESs). In this study, we analyzed the impact of diabetes mellitus (DM) on procedural characteristics, complications, and acute outcomes in a cohort of 440 patients.
Methods: Between 2012 and 2016, we recruited 440 consecutive patients, 116 of them with DM. All the patients underwent PCI for at least 1 CTO. Antegrade and retrograde CTO recanalization techniques were applied. Only third-generation DESs were used. We used t-tests and the Pearson chi-quadrat test to test the significant differences in the variables between the 2 groups.
Results: The patients with DM were older than the nondiabetics (64.5 y vs. 61.1 y; P=0.003), and they suffered more frequently from a chronic kidney disease (7.1% vs. 2.4%; P=0.001). The nondiabetics less frequently had arterial hypertension (75.3% vs. 89.7%; P=0.001); however, they more often had a family liability for CAD (32.1% vs. 22.4%; P=0.050) and had a higher left ventricular  ejection fraction (59.2% vs. 56.7%; P=0.011). The success rate was 85.2% in the patients without DM and 81.2% in the patients with DM (P=0.403). The existence of DM had no impact on the procedural success and complication rates.
Conclusion: Our study on 440 patients shows that diabetics and nondiabetics have similar success and complication rates after the recanalization of CTOs using third-generation DESs. It is a feasible and safe procedure and can be recommended as an alternative treatment.

Background: Percutaneous coronary intervention (PCI) has become the first-choice treatment strategy the world over for patients with chronic coronary artery disorders. This study compared the effects of previous PCI procedures on the short-term postoperative results of coronary artery bypass graft surgery (CABG).
Methodsː This cross-sectional analytical study recruited 220 patients who underwent CABG in Afshar Hospital in the Iranian city of Yazd between March 2009 and February 2013. The mean postoperative morbidity and mortality rates, the mean postoperative left ventricular ejection fraction (LVEF), the mean hemorrhage volume, the mean serum urea level, and the mean length of stay in the intensive care unit (ICU) were compared between the PCI and non-PCI groups.
Results: Among the 220 participants, 147(66.8%) were male and 73(33.2%) were female. The mean age of the study population was 59.41±10.52 years. There was no significant difference in the risk of mortality between the 2 groups (P=0.369). The mean serum urea level was 21.14±6.52 mg/dL in the PCI group and 14.45±1.08 mg/dL in the non-PCI group (P=0.016). The mean postoperative LVEF was 43.19±8.81% in the PCI group and 45.51±8.15% in the non-PCI group (P=0.044). The mean length of stay in the ICU was 3.34±1.23 days in the PCI group and 2.22±0.56 days in the non-PCI group (P<0.001). The mean hemorrhage volume was 1113.01±428.13 mL in the PCI group and 961.42±228.31 mL in the non-PCI group (P=0.027).
Conclusion: Previous PCI procedures did not affect the post-CABG mortality rate; however, some postoperative results were worse in the PCI group than in the non-PCI group, which should be considered before the selection of the revascularization method.

Background: Development of contrast-induced acute kidney injury (CI-AKI) in patients with ST-elevation myocardial infarction (STEMI) treated via primary percutaneous coronary intervention (PCI) is a major cause of morbidity and mortality worldwide. The neutrophil-to-lymphocyte ratio (NLR), which is a marker of inflammation, has been demonstrated to be associated with the development of major adverse cardiovascular outcomes in many studies. From this point of view, in this study, we aimed to evaluate the predictive value of the NLR as regards the occurrence of CI-AKI in patients with STEMI undergoing primary PCI.
Methods: This study was conducted at Dr. Siyami Ersek Training and Research Hospital from May 2008 to June 2016. A total of 2000 patients with STEMI treated via primary PCI were enrolled in the study. The NLR was calculated as the ratio of the number of neutrophils to the number of lymphocytes. All venous blood samples were obtained within 8 hours after admission. CI-AKI was the primary end point of the study. Then, the relationship between CI-AKI and the NLR was assessed.
Results: CI-AKI was detected in 148 (7.4%) patients. The patients who developed CI-AKI had a significantly higher NLR than those who did not (7.08±4.43 vs. 6.18±3.98; P=0.011). In the multivariate logistic regression analyses, the NLR remained a significant independent predictor of CI-AKI (OR: 1.78, 95% CI: 1.21–2.61, and P=0.003).
Conclusion: The NLR may be a significant independent predictor of CI-AKI in patients with STEMI treated via primary PCI and higher NLR values could be independently associated with a greater risk for CI-AKI.

Background: Postoperative cognitive decline is a common complication observed frequently after general anesthesia in the immediate postoperative phase. We studied the effects of dexmedetomidine versus midazolam during coronary artery bypass graft (CABG) surgery on cognitive and memory function. 
Methods: In this clinical trial, 42 elective on-pump CABG candidates under general anesthesia, aged between 40 and 65 years, were enrolled randomly in 2 groups. Group A received 0.05–0.1 mg/kg of midazolam and Group B received 1 µg/kg of dexmedetomidine. One day before surgery, all the participants underwent the Persian version of the Mini-Mental State Examination (MMSE) and the Persian version of the Wechsler Memory Scale (WMS) test for a comparison of cognitive impairment and memory functions. Both groups were given fentanyl and propofol for the induction of anesthesia and muscle relaxants. The MMSE and WMS tests were repeated 5 and 30 days after surgery.
Results: The mean±SD of age was 55.47±7.18 y in Group A and 55.39±6.08 y in Group B. Eighty percent of the participants were men in both groups. There were no significant differences between Group A and Group B in the MMSE and WMS before surgery (89.04±14.30 vs. 97.10±18.10, respectively;  P=0.059), but the WMS was significantly different 30 days after surgery (87.60±14.30 vs. 103.53±19.93, respectively; P=0.005). Group A showed high cognitive impairment and low WMS scores compared with Group B (P=0.005). Additionally, the MMSE results were not statistically different between the 2 groups postoperatively (24.80±3.18 vs. 23.55±4.18, respectively; P=0.394).
Conclusion: Our results showed that dexmedetomidine might have a lower impact on cognitive function than might midazolam among patients undergoing CABG.

Background: Acute hypoxemia is the main characteristic of acute respiratory distress syndrome (ARDS), which is one of the most critical complications of coronary artery bypass grafting (CABG). Given the dearth of data on acute hypoxemia, we sought to determine its prevalence and risk factors among post-CABG patients.
Methods: This cross-sectional study was conducted on on-pump CABG patients in Tehran Heart Center in 2 consecutive months in 2012. The effects of arterial blood gas variables, age, gender, the duration of the pump and cross-clamping, the ejection fraction, the creatinine level, and the body mass index on the prevalence of hypoxemia at the cutoff points of ARDS and acute lung injury were assessed.
Results: Out of a total of 232 patients who remained in the study, 174 (75.0%) cases were male. The mean age was 60.60±9.42 years, and the mean body mass index was 27.15±3.93 kg/m². None of the patients expired during the current admission. The ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO₂/FiO₂) 1 hour after admission to the intensive care unit (ICU), before extubation, and at 4 hours after extubation was less than 300 mmHg in 66.6%, 72.2%, and 86.6% of the patients and less than 200 mmHg in 20.8% 17.7%, and 30.2% of the patients, respectively. Among the different variables, only a heavier weight was associated with a PaO₂/FiO₂ ratio of less than 300 mmHg at 1 hour after ICU admission and at 4 hours after extubation (P=0.001). A rise in the cross-clamp time showed a significant association with the risk of a PaO₂/FiO₂ ratio of less than 200 mmHg at 4 hours after extubation (P=0.014).
Conclusion: This study shows that hypoxemia following CABG is very common in the first 48 postoperative hours, although it is a benign and transient event. The high prevalence may affect the accuracy of the ARDS criteria and their positive or negative predictive value.

We report a case of a type B aortic dissection with an aneurysm treated by the replacement of the proximal descending thoracic aorta via the reversed elephant trunk technique. A 48-year-old asymptomatic man was diagnosed with a type B aortic dissection, moderate aortic regurgitation, and a good biventricular function in March 2012. Four years later (April 2016), a contrast-enhanced computed tomography examination revealed an aneurysmal dilatation in the patient’s descending thoracic aorta with a thrombosis in the proximal part of the false lumen, which warranted surgical repair. He underwent type B aortic dissection repair through the left posterolateral thoracotomy. Three months after the surgery, the patient developed a type A aortic dissection with severe aortic regurgitation, which was successfully managed via a Bentall procedure with arch replacement facilitated by the reversed elephant trunk technique performed during the initial surgery through thoracotomy. At 2 years follow-up, the patient was doing well with a normal left ventricular function.

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or who are unsuitable candidates for open-heart surgery. However, concerns exist over treating patients who have undergone previous mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a case in which a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement was successfully treated with TAVI using a Portico valve, which is under-researched.

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