cTnT can be a useful marker for early detection of anthracycline cardiotoxicity.

BACKGROUND: The level of serum cardiac troponin-T (cTnT) increases with myocardial damage. We sought to assess whether cTnT level could be a useful marker for the early detection of anthracycline cardiotoxicity. PATIENTS AND METHODS: Forty-one patients who had been scheduled to receive anthracycline-containing combination chemotherapy were included in the study. Serum cTnT levels were measured before (baseline) and after the first cycle of chemotherapy, and again, after the last cycle of chemotherapy. In all patients, the left ventricular ejection fraction (LVEF), fractional shortening (FS), early peak flow/atrial flow velocity (E/A) ratio, and the isovolemic relaxation time (IRT) were measured echocardiographically, both before and after the completion of chemotherapy. RESULTS: LVEF and FS did not change in any patients. In 21 patients (49%), the E/A ratio decreased after therapy as compared to the pre-treatment values. The decrease in E/A ratio was more prominent in patients who were older than the mean age of our study group, which was 44 years. The post-treatment IRT was prolonged compared with the pretreatment IRT (94.0 +/- 2.0 versus 85.6 +/- 10.5 ms, respectively). cTnT levels after completion of therapy were elevated in 14 (34%) patients, and exceeded the upper limit of the normal range (>0.1 ng/ml) in only one patient. cTnT levels measured after completion of therapy were significantly higher, compared with those measured at baseline and after the first cycle of therapy. In the younger age group (< or =44 years old), there was a two-fold decrease in the E/A ratio in those patients whose cTnT levels increased during the therapy, when compared with those whose cTnT levels did not change (21% versus 43%, respectively). CONCLUSION: Increased serum cTnT level can be detected in the early stages of anthracycline therapy and it is associated with diastolic dysfunction of the left ventricle. Therefore, serum cTnT level could be a useful measure for early detection of anthracycline-induced cardiotoxicity.

Hepatoblastoma in children.

Hepatoblastoma is the most common primary liver tumour in children. Complete surgical removal is the treatment of choice for cure; however, in most cases the tumour is unresectable because of its extensive hepatic involvement. Nineteen pediatric cases (11 boys, 8 girls) with ages ranging from three months to 17 years were referred for management to our clinic from 1982 until 2000. All but three suffered from abdominal distention. The other frequent complaints were abdominal mass, anorexia, fatigue, abdominal pain and fever. Physical examination revealed enlarged liver in all patients. In addition to laboratory studies, they were pre-operatively examined by ultrasonography and, in recent cases, computed tomography was also used. Serum alpha-fetoprotein levels were found to be elevated in all patients. In thirteen cases, hepatic resections (10 lobectomies, 2 trisegmentectomies, 1 segmentectomy) were performed. In six children only liver biopsies could be done because of the huge tumour size. However, in three of them the tumours were excised at the second laparotomy, but only one patient survived. All of the patients - except two who were lost in the early postoperative period - received chemotherapy whether the tumour was excised or biopsied. In this series the mortality rate was found to be very high (91%) in the 1980s, and more reasonable (50%) in the 1990s, with an overall mortality rate of 73 per cent. This result might be explained with late referral and advanced stage at diagnosis. In addition, we speculate that a combination of improved chemotherapy and technical advances in anesthesia and hepatic resection caused the obvious differences in the survival rates between the two periods.

Treatment of intestinal pseudo obstruction by segmental resection.

Intestinal pseudo-obstruction refractory to medical therapy is a debilitating problem for specialists dealing with gastrointestinal disorders. We report the case of a newborn who developed severe, recurrent symptoms of intestinal obstruction, due to visceral myopathy. The case was persistently intractable to medical management, leading to repeated laparotomies. Gastrointestinal lesions showed marked dilatation of the entire digestive tract, with enlarging to enormously distended segments at two areas. Resection of these segments improved bowel function, facilitating enteral nutrition. Long-term hyperalimentation and repetitive hospitalizations were also avoided with this procedure. These results suggest that segmental resections can save unnecessary intestinal resections in cases with extensive gastrointestinal involvement.

Echocardiographic evidence of cardiac involvement in ankylosing spondylitis.

Aortic insufficiency, myocardial fibrosis and conduction disturbances are known complications of ankylosing spondylitis (AS). However, few studies have assessed left ventricular diastolic function and no data are available about P-wave analysis. In this study 88 AS patients and 31 healthy volunteers underwent clinical examination, electrocardiography, echocardiography and signal-averaged P-wave analysis for the evaluation of asymptomatic cardiac involvement. The aortic root in AS patients was larger and this was correlated with the duration of the disease. Five of 88 AS patients (5.7%) had evidence of mitral valve prolapse, six (6.8%) had thick and redundant mitral valves without prolapse, five (5.7%) had mild mitral regurgitation, two had moderate (2.3%) and two had mild (2.3%) aortic regurgitation. Examination of diastolic function revealed a lower peak of E-wave velocity (E) and E/A ratio, a higher peak of A-wave velocity (A) and acceleration rate of the A wave, a longer deceleration time of E-wave velocity and isovolumic relaxation time in the AS group compared to controls. Mean filtered P-wave duration (PWD) in AS was similar to that of controls. However, PWD in AS patients was positively correlated with left atrial dimension and acceleration rate of the A wave and negatively correlated with E and E/A ratio. In conclusion, cardiac involvement may be seen in AS patients in the absence of clinical manifestations. Echocardiographic examination of diastolic function can be used in this asymptomatic period. Further studies are needed to clarify the prognostic significance of diastolic abnormalities and the value of P-wave analysis in cardiac evaluation of these patients.

Effect of balloon-induced acute ischaemia on P wave dispersion during percutaneous transluminal coronary angioplasty.

AIMS: P wave dispersion is a recent ECG marker that reflects discontinuous and inhomogeneous conduction of sinus impulses, which has been studied in a limited number of cardiac conditions. The aim of our study was to investigate the effects of angioplasty induced-ischaemia on atrial conduction abnormalities as estimated by P maximum and P dispersion. METHODS AND RESULTS: The study consisted of 67 consecutive patients (41 men, mean age 58 +/- 11 years) with 1-vessel coronary artery disease who underwent elective single vessel coronary angioplasty (left anterior descending (LAD) coronary artery in 28 patients, the right coronary artery (RCA) in 22 patients and the left circumflex coronary artery (LCx) in 17 patients. All patients underwent 12-lead surface ECG before the first inflation (baseline) and then 60 s after intra-coronary balloon inflation. The maximum P wave duration, the minimum P wave duration, and P wave dispersion (Pd=Pmax - Pmin) were calculated from 12-lead surface ECGs. Baseline P wave duration measurements were not significantly different among the patients with LAD, RCA and LCx coronary artery disease (P>0.05). P dispersion and P maximum were significantly higher during balloon occlusion compared with the baseline condition in all three types of coronary dilatation procedures. However, P minimum was not found to differ between baseline and during balloon occlusion (P>0.05). CONCLUSION: The prolongation of P wave dispersion may be a useful and simple additional marker for myocardial ischaemia.

Comparison of electromagnetic field stimulation on the healing of small and large intestinal anastomoses.

PURPOSE: Magnetic fields have been shown to affect biologic processes. Accordingly, an experimental study was designed to investigate the effect of electromagnetic field stimulation on intestinal healing and to compare small and large intestinal anastomoses. METHODS: An ileal or a colonic anastomosis was constructed in rats. Beginning the day after surgery, randomly assigned groups were exposed to sinusoidal electromagnetic field stimulation of 10.76-mT intensity and 50-Hz frequency, with 2-hour-on/10-hour-off cycles. After seven days, intestinal anastomoses were assessed for hydroxyproline content and breaking strength. Statistical comparison between each experimental and control group yielded significance (P < 0.05) in all cases. RESULTS: Hydroxyproline content increased significantly in ileum from 1.650 +/- 0.11 (mean +/- standard error of the mean) to 2.036 +/- 0.11 microg/mg (P = 0.0249) and in colon from 1.526 +/- 0.11 to 1.922 +/- 0.11 microg/mg (P = 0.0135). Breaking strength also increased significantly in ileum from 0.213 +/- 0.01 to 0.255 +/- 0.01 MPa (P = 0.001) and in colon from 0.227 +/- 0.01 to 0.270 +/- 0.01 MPa (P = 0.006). CONCLUSIONS: Electromagnetic field stimulation provided a significant gain in anastomotic healing in both small and large intestine. There were no apparent differences detected between the healing of small and large intestinal anastomoses except for slight differences in the time sequences of events and magnitude. The study demonstrated a significant increase in both biochemical and mechanical parameters. Additional investigations are needed to determine optimal conditions and promote selective biologic responses.

Extent of coronary atherosclerosis and homocysteine affect endothelial markers.

The aim of the study was to evaluate the effects of the presence, extent, and clinical stability of coronary artery disease on endothelial function parameters, C-reactive protein and homocysteine levels. Fifty-eight patients with angiographically documented coronary artery disease and 25 patients with normal coronary arteries were evaluated for risk factors, plasma homocysteine, C-reactive protein, and soluble adhesion molecule levels. Vascular cell adhesion molecule-1 and sE-selectin were significantly higher in the group with coronary artery disease than in healthy subjects (p = 0.005 and p = 0.031, respectively). Patients with unstable angina had significantly higher C-reactive protein (p < 0.001), troponin I (p < 0.01), and leukocyte counts (p < 0.05) than those with stable angina. sE-selectin levels were correlated with the extent of coronary atherosclerosis (r = 0.444, p < 0.05), and plasma homocysteine levels were associated with vascular cell adhesion molecule-1 (r = 0.479, p < 0.05) in unstable cases. These results suggest that vascular cell adhesion molecule-1 and sE-selectin are useful for determining the presence of coronary atherosclerosis, whereas C-reactive protein, troponin 1, and leukocyte count are predictors of clinical stability.

No evidence of cardiac autonomic involvement in ankylosing spondylitis, as assessed by heart rate variability.

The aim of this study was to investigate the involvement of autonomic nervous system (ANS) function by using power spectral analysis of heart rate variability (HRV) method in patients with ankylosing spondylitis (AS). The study included 94 AS patients all fulfilling the New York criteria for AS, and 49 healthy volunteers. Recordings for HRV were obtained with a PC-based high-resolution electrocardiographic system and analysed using power spectral analysis. The peak around 0.04-0.15 Hz was defined as low-frequency peak (LF) and the other, around 0. 15-0.40 Hz, was defined as high-frequency peak (HF), representing mostly the sympathetic and the parasympathetic components of the ANS, respectively. The following variables were calculated and compared between groups: the LF in absolute and normalised units (LF nU); the HF in absolute and normalised units (HF nU); and LF/HF ratio. The AS group included 47 male and 47 female subjects with a mean age of 33 +/- 11 years (range 16-64). In the control group there were 23 male and 26 female healthy subjects (mean age 33 +/- 8; range 19-60). None of the patients or control subjects had any cardiac or neurological symptoms. Both groups were similar with respect to age and sex characteristics (p > 0.05). The HRV analysis indicated that the peaks of LF, LF nU, HF, HF nU and LF/HF ratio were similar in both groups. Groups also did not differ with respect to heart rate at the time of examination. Our data demonstrated no evidence of ANS involvement as assessed by HRV analysis in AS patients.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common.

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas.

Ten patients were enrolled in this study to evaluate the therapeutic value of percutaneous balloon pericardiotomy in patients with symptomatic pericardial effusion secondary to malignant diseases. Four patients had breast cancer; 2 had lung cancer; 1 had non-Hodgkin's lymphoma; and 3 had malignant pleural mesothelioma, which is commonly seen in Central Anatolian region of Turkey. All patients underwent percutaneous balloon pericardiotomy with monofoil balloons (Mansfield, NuMed). No complication was seen during these procedures. In 3 patients, the balloon could not be expanded completely and was entered from a more lateral position by a second puncture. There was no recurrence of pericardial effusion in 6 of 7 patients without mesothelioma. After percutaneous balloon pericardiotomy, surgical subxiphoid windowing was performed due to drainage greater than 100 mL/day in a patient with lung cancer and in 1 patient with mesothelioma. In the other 2 patients with mesothelioma, recurrence of pericardial effusion was seen and then subxiphoid surgical windowing was performed due to development of cardiac tamponade in 1 of them. All the patients died 68.6 +/- 36 days later due to the primary malignancies. The survival time of patients with mesothelioma was shorter than that of the others (p < 0.05). These results suggest that percutaneous balloon pericardiotomy may be used in the treatment of patients with malignant pericardial effusion as an alternative to surgical pericardial window creation. But in patients with malignant pleural mesothelioma, the success rate of this procedure was lower than that of the others.

Acute anterior myocardial infarction following a mild nonpenetrating chest trauma--a case report.

Myocardial infarction in patients under age 45 years is a relatively unusual phenomenon; blunt chest trauma is one of the nonatherosclerotic mechanisms leading to acute myocardial infarction in young adults. The authors report a rare case of anterior myocardial infarction in a 22-year-old man following a mild nonpenetrating chest trauma whose left chest was elbowed during a soccer game.

Platelet and leukocyte deactivation after intracoronary stent placement in patients receiving combined antiplatelet therapy.

Activated platelets and leukocytes have been demonstrated to play a role in the development of stent thrombosis, and coronary angioplasty has been shown to result in activation of platelets, leukocytes, and endothelial cells. We aimed to evaluate the effects of intracoronary stent placement and aspirin plus ticlopidine treatment on platelets, leukocytes, and endothelial cells via observing the serial changes in the circulating soluble forms of adhesion molecules in 54 patients with coronary artery disease, who had elective coronary angioplasty and stent implantation for a single lesion of the left anterior descending artery. After stent placement, intravenous heparin infusion was administered only for 24 hours, and aspirin plus ticlopidine treatment was applied for 1 month. Venous blood samples were drawn before stent placement, and repeated 24 and 48 hours after the procedure. Patients were excluded if they had had recent cardiovascular events or any illness that might influence platelet, leukocyte, and endothelial cell function. The plasma level of sL-selectin was significantly decreased 48 hours after coronary stenting (636+/-110 ng/mL vs 567+/-93 ng/mL; P = 0.001, respectively). Likewise, the plasma level of sP-selectin was also decreased significantly 48 hours after the procedure (260+/-61 ng/mL vs 233+/-83 ng/mL, P = 0.01). The sE-selectin level was found to be significantly increased 24 hours (31+/-9 ng/mL vs 39+/-12 ng/mL, P = 0.0001) and 48hours(31+/-9 ng/mL vs 42+/-15 ng/mL, P = 0.001) after coronary stenting. The results of our study suggest that significant platelet and leukocyte deactivation take place in patients treated with combined antiplatelet therapy after stenting; endothelial cell activation also occurs during this treatment.

Hydatid cyst of the heart as a rare cause of embolization: report of 5 cases and review of published reports.

Cardiac hydatid cyst is seen infrequently, even in regions where hydatid cysts are endemic. We report 5 cases of cardiac hydatid cysts, which were diagnosed after an embolic event.

Increased plasma levels of soluble selectins in patients with unstable angina.

BACKGROUND: Inflammation plays an important role in the pathogenesis of unstable angina. Adhesion molecules, such as selectins, mediate the interactions between leukocytes, platelets and endothelial cells during inflammation and thrombogenesis. HYPOTHESIS: The purpose of this study was to determine whether soluble E-selectin, P-selectin and L-selectin levels are increased in patients with unstable angina (UA). METHODS: Soluble E-, P- and L-selectin levels were measured by enzyme-linked immunoassay in the peripheral blood of 23 patients with UA, 26 patients with stable angina (SA) and 15 control patients with angiographically normal coronary arteries. RESULTS: Soluble E-selectin levels were significantly higher in patients with UA (45+/-11 ng/ml) than in controls (30+/-8 ng/ml, P<0.001), or patients with SA (34+/-8 ng/ml, P=0.001). Similarly, plasma levels of P- and L-selectin were significantly higher in patients with UA (427+/-144 and 772+/-160 ng/ml, respectively) than in patients with SA (278+/-79 and 643+/-94 ng/ml, respectively, P<0.005 vs. UA for both), or control patients (189+/-43 and 601+/-126 ng/ml, respectively, P=0.001 vs. UA for both). CONCLUSIONS: Plasma levels of soluble selectins were increased in patients with UA compared with patients with SA or patients without angiographically visible coronary artery disease. Measurements of these adhesion molecules may be helpful as non-invasive markers of coronary plaque destabilization in UA.

Effects of stent coating on platelets and endothelial cells after intracoronary stent implantation.

BACKGROUND: Adhesion molecules are known to be important in the regulation of endothelial cell and platelet functions. Increased platelets P-selectin expression is a marker of stent thrombosis after uncoated stent placement. HYPOTHESIS: The aim of this study was to compare the effects of intracoronary placement of phosphorylcholine (PC)-coated, versus heparin-coated, versus uncoated stents on platelets and endothelial activity. METHODS: Thirty patients (age 55 +/- 10, 27 men) with significant proximal left anterior descending coronary artery stenoses were randomized to elective implantation of PC-coated, versus heparin-coated, versus uncoated stents. Following stent placement, intravenous heparin and aspirin plus ticlopidine were administered. Venous plasma soluble E-selectin, sP-selectin, and intercellular adhesion molecule-l levels were measured before the procedure and 24 and 48 h thereafter as markers of platelet and endothelial cell activation. Patients were excluded if they had a disease known to influence platelet and endothelial cell function. RESULTS: Plasma sP-selectin levels decreased significantly after implantation of PC- and heparin-coated stents (p = 0.04), but remained unchanged in patients randomized to uncoated stents. Plasma sE-selectin levels increased significantly after uncoated stent placement (p = 0.04) and remained unchanged after coated stent implantation. CONCLUSION: In patients treated with combined antiplatelet therapy, implantation of PC- and heparin-coated stents decreased platelet activity without activating endothelial cells, whereas placement of uncoated stents led to endothelial activation without changing platelet activity. These results suggest that PC-coated and heparin-coated stents may be advantageous in limiting thrombotic complications.

Verapamil SR and trandolapril combination therapy is safe and effective in hypertensive patients with metabolic disorders.

Verapamil SR (180 mg) plus trandolapril (2 mg) is a potent antihypertensive combination but the efficacy and safety of this treatment has not been studied fully in hypertensive patients with metabolic disorders. We enrolled 298 patients with mild to moderate hypertension who had at least one of the following disorders: diabetes mellitus, hypercholesterolaemia or mild renal failure. The sitting systolic pressure and diastolic blood pressures were significantly decreased after 12 weeks of treatment. Blood pressure was inadequately controlled in only 24 patients (8.8%). Progressive decreases in blood glucose, total cholesterol, low-density lipoprotein and triglyceride levels were observed during the study. There was no significant change in blood urea nitrogen, creatinine and transaminase levels (p > 0.05). There was a significant decrease in microalbuminuria levels. There was no significant change in glycosylated haemoglobin levels in diabetic patients. Verapamil SR plus trandolapril is an effective drug combination in the treatment of hypertension. It may be used safely in patients with diabetes mellitus, hyperlipidaemia and mild renal failure.

A huge mitral valve tumor and its vascularity--a case report.

Primary cardiac tumors of the mitral valve are extremely rare; however, they present a major risk of embolization. Therefore, prompt diagnosis and urgent treatment is obligatory. The authors report the case of a 60-year-old man with a huge mitral valve mass and its vascularity, which was diagnosed by transthoracic echocardiography and selective coronary arteriography. Our patient's mitral valve tumor had a size of 5.9 x 2.9 cm, which was the largest size reported up to this time in this location. The patient died from a major cerebrovascular event before surgical excision could be performed.

T wave alternans can decrease after coronary revascularization.

Clinical observations and animal experiments indicate that T wave alternans (TWA) is associated with an increased propensity for ventricular fibrillation, and thus it may be considered as a noninvasive marker of life-threatening ventricular arrhythmias. There is substantial evidence indicating that TWA is an intrinsic property of ischemic myocardium. This study was performed to determine the role of percutaneous transluminal coronary angioplasty (PTCA)-induced myocardial ischemia in the development of TWA and the effects of revascularization. The authors recorded bipolar X, Y, and Z leads of 111 consecutive patients (mean age: 56 years) undergoing PTCA before, during, and 24 hours after the procedure. T wave alternans signal was calculated in 97 patients (43 left anterior descending, 26 right coronary artery, and 28 circumflex or major obtuse margin branch) by fast Fourier transformation technique after signal processing. Twenty-four hours after the procedure, the mean and peak X, Y, and Z values for TWA had all been significantly reduced from baseline and during balloon inflation (p<0.01). The findings point out that induced ischemia could be a trigger for T wave alternans, and successful revascularization can reduce alternans.

QT dispersion as a predictor of arrhythmic events in patients with ankylosing spondylitis.

OBJECTIVE: The aim of the study was to evaluate QT dispersion (QTd), an indicator of repolarization heterogeneity, and its relation to ventricular arrhythmias in patients with ankylosing spondylitis (AS). METHODS: A full history, clinical examination, electrocardiograms and 24-h Holter monitoring were performed in 88 AS patients and 31 volunteers of similar age and sex. Groups were compared based on electrocardiographic abnormality, QTd, arrhythmias and heart blocks. RESULTS: QTd and corrected QTd (QTcd) were significantly greater in AS patients than controls (QTd, 52.8 +/- 15.1 vs 35.5 +/- 8.9 ms, P: < 0.0001; QTcd, 60.3 +/- 16.1 vs 39.4 +/- 10.7 ms, P: < 0.0001). The magnitudes of these parameters were associated with the duration of the disease (QTd, r = 0.56, P: < 0.01; QTcd, r = 0.60, P: < 0.001). The frequency of ventricular extrasystoles was found to be correlated with QTd (r = 0.35, P: < 0.01) and QTcd (r = 0.33, P: < 0. 01). CONCLUSION: Involvement of the heart may be seen in AS during the early clinical course of the disease. QTd may give clues about the presence of arrhythmias and can be used as a new technique for the evaluation of asymptomatic patients. Earlier detection of cardiac involvement could alter the prognosis of the patients.