Association of ST elevation with apical aneurysm in hypertrophic cardiomyopathy.

OBJECTIVES: Apical aneurysms in patients with hypertrophic cardiomyopathy (HCM) represent an underrecognized but clinically important subset of HCM patients. However it may be frequently missed by echocardiography because of poor image quality of left ventricular apex. We aimed to compare electrocardiographic STE in HCM patients with and without apical aneurysm. METHODS: We developed this clinical review using an extensive MEDLINE review of the literature and data from our laboratories; and some electrocardiographic parameters including STE were analysed in HCM patients with and without apical aneurysm. RESULTS: There were 29 HCM patients without apical aneurysm (Group 1; 52.6±17.7years, 69% male) and 28 HCM patients with apical aneurysm (Group 2; 59.6±13.2years, 57% male). The STE in V4-6 derivations were statistically more frequent in patients with apical aneurysm compared to those without aneurysm (93% vs 7%, p<0.001). There was a positive correlation between the presence of the STE in V4-6 derivations and the presence of the apical aneurysm (Spearman's ρ=0.895, p<0.001). CONCLUSIONS: Clinicians and specifically echocardiographers must pay special attention on the electrocardiography to correctly detect the frequently overlooked apical aneurysm in HCM patients, and should be careful for apical aneurysm particularly in the presence of STE in V4-6 derivations.

Association of prediabetes with diffuse coronary narrowing and small-vessel disease.

BACKGROUND: A significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics. OBJECTIVE: To evaluate whether there is an association between prediabetes and the coronary arterial size. METHODS: We prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as "normal," "prediabetic," and "diabetic" groups, and the coronary artery sizes and Gensini scores were analyzed. RESULTS: There were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p<0.001 in female group; Spearman's ρ: 0.252 p=0.016 in male group). CONCLUSION: We found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.

Pulmonary artery distensibility in chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary hypertension (PH) is an important complication in the natural history of chronic obstructive pulmonary disease (COPD) and is caused by the remodeling of pulmonary arteries impairing the distensibility and stiffness of the major pulmonary arteries. OBJECTIVES: To evaluate the pulmonary artery distensibility by transthoracic echocardiography in patients with COPD. METHOD: We prospectively investigated COPD male patients and compared with healthy controls. In addition to right ventricle (RV) conventional echocardiographic parameters, right pulmonary artery fractional shortening(RPA-FS) and new pulmonary artery stiffness (PAS) parameters were compared. RESULTS: Fifty-four COPD patients participated in the study and compared with a control group consisting of 24, all men, healthy, nonsmoking subjects. Six patients were excluded from study due to poor quality of echocardiographic recordings. The distensibility of PA evaluated by the RPA-FS parameter was found to be significantly lower in patients with COPD than it was in normal subjects (13.3 ± 8.1 vs. 27.6 ± 4.9,P :< 0.001) and correlated positively with tricuspid annular systolic excursion (TAPSE) (r = 0.566, P < 0.001) and pulmonary acceleration time (r = 0.607, P < 0.001) and correlated inversely with pulmonary artery systolic pressure (r = -0.587, P < 0.001), PAS(r = -0.479, P < 0.001) and functional capacity (r = -0.586, P < 0.001). Similar to this, PAS found to be impaired in COPD patients (29.5 ± 13.6 vs. 15.7 ± 4.1, P < 0.001) and correlated inversely RPA-FS (r = -0.479, P < 0.001). There were statistically significant difference for pulmonary artery distensibility (RPA-FS) and PAS parameters among the COPD subgroups with regard to NYHA functional capacity (P < 0.001). CONCLUSION: In this study, we found that PAS and distensibility were worsened in COPD patients and correlated with decreased functional capacity.

The role of the preoperative screening of sleep apnoea by Berlin Questionnaire and Epworth Sleepiness Scale for postoperative atrial fibrillation.

BACKGROUND: Undiagnosed obstructive sleep apnoea (OSA) is a risk factor for postoperative atrial fibrillation (POAF) as well as for heart disease in general. This necessitates screening during preoperative assessment to facilitate the implementation of strategies to minimise the postoperative risk. Overnight polysomnography is the "gold standard" for the diagnosis of OSA but may be impractical during preoperative assessment, and so questionnaires may be useful for screening OSA. The Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS) are two of the widely prescreening tools for persons who may suffer from sleep disorders. Thus, screening for and treating OSA as part of the routine preoperative evaluation of cardiac surgical patients may be a useful strategy for preventing POAF. OBJECTIVE: We investigated whether there is an association between POAF and sleep disorders evaluated by the BQ and ESS in this settings. METHODS: In 73 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and operational data were examined. During the clinical evaluation, all patients answered the ESS and BQ voluntarily upon admission. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalised. RESULTS: There were 33 patients with POAF and 40 patients without POAF as age- and gender-matched controls. The prevalence of high score in ESS was higher in POAF group compared to control group (52% vs 27%; p: 0.030). There was a higher prevalence of high risk for OSA in BQ in the POAF group (58% vs 34%; p: 0.044). CONCLUSION: Preoperative questionnaire-based diagnosis of OSA by the simple BQ and ESS may be useful in predicting POAF, and can be easily incorporated into routine screening of surgical patients undergoing CABG operation.

Intramyocardial hematoma with epicardial rupture following percutaneous coronary intervention.

Intramyocardial (or subepicardial) hematomas are uncommon conditions that occur mostly after myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass surgery, cardiac surgery, or chest trauma. Coronary perforation is a rare complication of PCI and the subset of patients developing an intramyocardial hematoma, usually considered a catastrophic event, is even rarer. We describe here the case of 63-year-old man in whom an intramyocardial hematoma with epicardial rupture occurred after PCI. The patient was treated conservatively with a successful outcome.

Exercise-related QT interval shortening with a peaked T wave in a boy with MEN 2 syndrome.

Multiple endocrine neoplasia 2 (MEN 2) is a hereditary syndrome associated with medullary thyroid carcinoma, pheochromocytoma (PCC), and hyperparathyroidism. PCCs in patients with MEN 2 are usually found in the adrenals after the manifestation of medullary thyroid cancer and are commonly bilateral and hormonally active. Unfortunately, a diagnosis of MEN 2 or PCC often is delayed until after the patient has developed an advanced MEN 2-related tumor. We present unusual electrocardiographic changes on exercise testing in MEN 2 syndrome. Transient peaked T waves and shortening QT during exercise stress testing may provide an early clue for undiagnosed PCC. .

A new electrocardiographic marker of myocardial reperfusion in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous intervention: the value of QRS duration.

AIMS: Although ischaemia-induced QRS complex changes have been described previously, their relation with reperfusion status is not clear. We aimed to investigate the relation of QRS duration with reperfusion at tissue level compared to myocardial blush in patients with acute myocardial infarction who underwent successful primary percutaneous coronary angioplasty. METHODS AND RESULTS: One hundred and forty-eight patients were enrolled. Based on the post-angioplasty myocardial blush grade (MBG), patients were divided into reperfusion (grades 2 and 3) and impaired reperfusion (grades 0 and 1) groups. Although the two groups did not differ in terms of admission QRS duration (81±17 vs. 79±15 msec, p=0.473), the patients in the impaired reperfusion group had a significantly longer QRS duration both at immediate post-angioplasty (78±18 vs. 68±17 msec, p=0.001) and at the 60th minute ECG (77±17 vs. 60±17 msec, p<0.001). Patients in the impaired reperfusion group revealed significantly less narrowing of QRS duration in the post-angioplasty 60th minute ECG (6±5 vs. 20±5 msec, p<0.001) when compared to the patients in the reperfusion group. After adjusting all variables, QRS narrowing in the 60th minute ECG was determined as an independent electrocardiographic predictor of reperfusion (OR:1.39, 95% CI: 1.25-1.54, p<0.001). CONCLUSIONS: We demonstrated that QRS duration is a strong indicator of myocardial reperfusion status.

Prognostic significance of neutrophil gelatinase-associated lipocalin in ST-segment elevation myocardial infarction.

OBJECTIVES: This study investigated the prognostic value of neutrophil gelatinase-associated lipocalin (NGAL) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Neutrophil gelatinase-associated lipocalin is a promising biomarker for acute kidney injury. Recently, it was concluded that NGAL may be used beyond the boundaries of renal physiopathology. It was found to be an important factor indirectly contributing to the inflammatory processes. Little is known regarding its predictive role in STEMI. METHODS: One hundred six consecutive patients who underwent percutaneous coronary intervention (PCI) for STEMI and control group consisted of age- and sex-matched 60 consecutive patients with chest pain admitted to the hospital for elective PCI. According to median NGAL level, patients were classified into high- and low-NGAL groups. RESULTS: Neutrophil gelatinase-associated lipocalin levels were higher in patients with STEMI compared to the elective PCI group subjects. Inhospital and 1-year mortality rates were found to be significantly greater in patients with high NGAL. In addition, inhospital and 1-year major adverse cardiovascular event rates were significantly greater in the high-NGAL group, compared to the low NGAL group. High NGAL level on admission was a significant predictor for long-term mortality and major adverse cardiovascular events. The receiver operating characteristics curve analysis further illustrated that NGAL level on admission is a strong indicator of mortality, with an area under the curve of 0.76 (95% confidence interval, 0.62-0.89). CONCLUSIONS: High NGAL levels may be associated with poor prognosis after PCI in patients with STEMI. However, further studies with larger numbers of patients and longer follow-up are required to evaluate the usefulness of plasma NGAL level for predicting prognosis of STEMI.

Ambulatory blood pressure variability is associated with restenosis after percutaneous coronary intervention in normotensive patients.

BACKGROUND: Previous studies have showed that BP variability is associated with cardiovascular events. However, no data were available regarding binary restenosis as an end-point after percutenous coronary intervention (PCI). METHODS AND RESULTS: This multicenter study included 100 consecutive normotensive patients with stable coronary artery disease who were planned for PCI. Before the index procedure, office BP and 24-h ambulatory BP measurements were performed. BP variability indices including systolic and diastolic 24-h average, the day and the night values of standard deviation (SD) and variation coefficient (VC) were measured and calculated. All patients underwent repeat coronary angiography at 6-month. According to angiographic results, 2 groups were formed; a restenosis group (n=30) with binary restenosis of the stented segment and a control group (n=70) with a stenosis diameter of <50% in stented segment. Systolic SD and VC values for 24-h average (14.0±2.8mmHg vs. 9.5±1.6mmHg, p<0.001 and 16%±3 vs. 11%±2, p<0.001, respectively), the day (15.2±3.9mmHg vs. 10.6±1.7mmHg, p<0.001 and 17%±4 vs. 12%±2, p<0.001, respectively), and the night (12.8±4.1mmHg vs. 8.4±2.4mmHg, p<0.001 and 14%±5 vs. 11%±3, p=0.004, respectively) values were significantly higher in restenosis group compared to control group. Similarly, diastolic SD and VC values for 24-h average (10.6±2.5mmHg vs. 8.1±1.5mmHg, p<0.001 and 12%±3 vs. 9%±2, p=0.001, respectively), the day (11.1±2.9mmHg vs. 9.0±1.8mmHg, p=0.003 and 12%±3 vs. 10%±2, p=0.006, respectively), and the night (10.0±3.6mmHg vs. 7.2±2.0mmHg, p=0.001 and 11%±5 vs. 9%±3, p=0.059, respectively) values were significantly higher in restenosis group compared to no restenosis group except for diastolic VC night. All systolic and diastolic BP variability indices except diastolic VC night were found to be independent predictors of risk of restenosis in multivariate analysis. In addition, the cut-off values of 11.4mmHg and 13% for 24-h systolic SD and VC, respectively, were found to be highly sensitive (93% for both) and specific (94% and 91%, respectively) for predicting binary restenosis at 6-month after PCI. CONCLUSIONS: BP variability indices are significantly and independently associated with binary restenosis and higher values can predict restenosis after PCI sensitively and specifically.

Elevated plasma asymmetric dimethylarginine level in acute myocardial infarction patients as a predictor of poor prognosis and angiographic impaired reperfusion.

OBJECTIVES: We aimed to investigate the effects of admission asymmetric dimethylarginine (ADMA) levels on myocardial perfusion and prognosis in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: ADMA, an endogenous inhibitor of endothelial nitric oxide synthase, was found to be elevated in plasma of patients with cardiovascular risk factors. METHODS: 168 consecutive patients undergoing primary PCI for STEMI <12 h after symptom onset and 75 healthy age and sex matched volunteer controls were enrolled in the study. Patients with STEMI were grouped into tertiles according to their admission plasma ADMA levels. Major adverse cardiac events during hospitalization or at one-year clinical follow-up were evaluated. Also angiographic impaired reperfusion was assessed by 3 different methods after PCI: angiographic thrombolysis in myocardial infarction (TIMI) flow, TIMI frame count and TIMI myocardial perfusion grade (TMPG). RESULTS: Plasma level of L-arginine were lower in patients with STEMI than in the control group subjects, whereas plasma ADMA levels were increased in the STEMI patient group. The rate of impaired angiographic reperfusion increased across the tertile groups. Also one-year mortality rates showed a significant increase across the tertile groups (4% vs. 10% vs. 20%, p<0.01). Using multiple Cox regression analysis, only TIMI risk score, left ventricle ejection fraction (LVEF), abnormal TMPG, and increased ADMA values on admission emerged as independent predictors of one-year mortality. The ROC analysis indicated an optimal cut-point of ≥1.37 µmol/L, which detects one-year mortality with a negative predictive value of 96%. CONCLUSIONS: In STEMI patients undergoing primary PCI, high admission ADMA levels were found to be associated with impaired myocardial perfusion and increased one-year mortality. Therefore admission ADMA level detection may be helpful in identifying the patients at a greater risk of impaired myocardial perfusion and poor prognosis.

[An effective and safe alternative to epicardial pacemaker placement for permanent pacemaker implantation in a patient with mechanical tricuspid valve: stimulation of the left ventricle through the coronary sinus]. / Mekanik triküspit protez kapagi olan bir hastada kalici kalp pili yerlestirilmesinde epikardiyal yaklasimin güvenli ve etkili seçenegi: Koroner sinüs yoluyla sol ventrikülün uyarilmasi

Implantation of a transvenous endocardial pacemaker is contraindicated in patients with a mechanical tricuspid valve. An epicardial left ventricular pacemaker lead was placed by a transvenous route through the coronary sinus into the lateral cardiac vein in a 58-year-old woman with mechanical aortic, mitral, and tricuspid valves, for permanent pacing due to chronic atrial fibrillation with a slow ventricular rate accompanied by syncope. This lead was then connected to a single-chamber pacemaker. The patient had no problem in the following three months. Placement of an epicardial pacing lead through the coronary sinus provides a safe and effective pacing in patients with a mechanical tricuspid valve, thus obviating major cardiac surgery.

Heart rate profile during exercise in patients with early repolarization.

BACKGROUND: Both early repolarization and altered heart rate profile are associated with sudden death. In this study, we aimed to demonstrate an association between early repolarization and heart rate profile during exercise. METHODS: A total of 84 subjects were included in the study. Comparable 44 subjects with early repolarization and 40 subjects with normal electrocardiogram underwent exercise stress testing. Resting heart rate, maximum heart rate, heart rate increment and decrement were analyzed. RESULTS: Both groups were comparable for baseline characteristics including resting heart rate. Maximum heart rate, heart rate increment and heart rate decrement of the subjects in early repolarization group had significantly decreased maximum heart rate, heart rate increment and heart rate decrement compared to control group (all P < 0.05). The lower heart rate increment (< 106 beats/min) and heart rate decrement (< 95 beats/min) were significantly associated with the presence of early repolarization. After adjustment for age and sex, the multiple-adjusted OR of the risk of presence of early repolarization was 2.98 (95%CI 1.21-7.34) (P = 0.018) and 7.73 (95%CI 2.84-21.03) (P < 0.001) for the lower heart rate increment and heart rate decrement compared to higher levels, respectively. CONCLUSIONS: Subjects with early repolarization have altered heart rate profile during exercise compared to control subjects. This can be related to sudden death.

Long-term follow-up data of coronary sinus stenting for the stabilization of the left ventricular leads.

BACKGROUND: Cardiac resynchronization therapy has been increasingly used for patients with heart failure. However, unstable and dislocated coronary sinus leads reduce the effectiveness of this important intervention. AIM: To examine the long-term effects of coronary sinus side branch stenting on sensing and pacing parameters of the left ventricular leads. METHODS: A total of eight patients (six males; two females; mean age, 56.6 ± 14.4 years) whose coronary sinus lead dislocated during the procedure were included in the study. Targeted coronary sinus side branch stenting was performed to stabilize the leads. Sensing and pacing parameters including lead impedance, capture threshold, and R-wave amplitude were measured at implantation, first month, sixth month, and every 6-month period. RESULTS: Mean follow-up period was 30.4 ± 7.4 months. At the time of implantation, lead impedance, capture threshold, and R-wave amplitude were 656 ± 162 Ω, 1.1 ± 0.5 V, and 13.0 ± 6.8 mV, respectively. No statistically significant mean lead impedance, capture threshold, and R-wave amplitude differences were observed between at the time of implantation and at the time of last follow-up (697 ± 164 Ω, 1.1 ± 0.5 V, 12.8 ± 6.9 mV, respectively). CONCLUSION: In this long-term study, coronary sinus side branch stenting for the stabilization of dislocated leads seems to be effective.

Paraoxonase activity might be predictive of the severity of aortic valve stenosis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve stenosis (AS) is the most common valvular heart disease in the western world, and in adults is invariably caused by the calcification of a normal tricuspid or congenital bicuspid valve. Calcific AS, as an active disease process, is characterized by lipid accumulation, inflammation and calcification that mimic atherosclerosis. Paraoxonase-1 (PON-1) is a high-density lipoprotein (HDL)-bound enzyme that exerts antiatherogenic properties by protecting low-density lipoprotein (LDL)-cholesterol from oxidative modification. The study aim was to examine the association between PON-1 activity and AS. METHODS: A total of 93 patients with angiographically normal coronary arteries was enrolled into the study. Transthoracic echocardiography was used to diagnose and grade the AS before the patients underwent selective coronary angiography. The patients were allocated to three groups of mild AS (n = 34), moderate AS (n = 31) and severe AS (n = 28). Paraoxonase activity was measured using a spectrophotometric technique. RESULTS: The mean PON-1 activity in patients with severe AS (64.4 +/- 29.8 U/l) was significantly lower than that in patients with mild and moderate AS (97.1 +/- 72.6 and 146.8 +/- 133.9 U/l; p = 0.03 and p = 0.002, respectively). Typically, PON-1 activity tended to be lower in moderate AS than in mild AS (p = 0.07). The serum PON-1 activity correlated positively with the aortic valve area, but negatively with the aortic mean and maximum gradients. CONCLUSION: The study results showed that PON-1 activity is lower in patients with calcific AS. In addition, PON-1 activity was inversely correlated with the severity of AS.

Risk factors for in-hospital mortality in infective endocarditis: five years' experience at a tertiary care hospital in Turkey.

BACKGROUND AND AIM OF THE STUDY: Despite recent improvements in diagnostic and therapeutic interventions, infective endocarditis (IE) is still associated with high in-hospital mortality rates. The study aim was to determine the clinical, laboratory and echocardiographic features of IE, and to evaluate the risk factors for in-hospital mortality. METHODS: A retrospective cohort study design was employed, with a main outcome measure of in-hospital mortality. A total of 107 patients (79 males, 28 females; mean age 45 +/- 16 years) admitted with the modified Duke criteria for definitive IE were included in the study during a five-year period between January 2004 and December 2008. RESULTS: Among the patients, the mitral valve alone was involved in 45% of cases, the aortic valve in 36%, tricuspid valve in 11%, and multiple valves in 8%. Forty-seven patients (44%) had prosthetic valves. Blood cultures were positive in 71 patients (66%). The most common isolated microorganisms were staphylococci, streptococci and Brucella melitensis. The in-hospital mortality rate was 27%. Leading causes of death were multi-organ failure and heart failure. In univariate analysis, factors associated with death were a longer duration of symptoms before hospitalization, previous history of IE, white blood cell count > or = 10,000/mm3, serum creatinine level > or = 2 mg/dl, vegetation size >15 mm, involvement of multiple valves, existence of severe regurgitation, cardiac abscess, and neurologic complications. Multivariate analysis showed that risk factors for mortality were multivalvular involvement (hazard ratio (HR) 4.7; 95% confidence interval (CI) 1.3-17.6; p = 0.021), vegetation size >15 mm (HR 5.5; 95% CI 2.1-14.6; p = 0.001), serum creatinine > or = 2 mg/dl (HR 4.1; 95% CI 1.8-9.4; p = 0.001), and previous history of IE (HR 3.5; 95% CI 1.2-11; p = 0.026). CONCLUSION: Multivalvular involvement, vegetation length >15 mm, serum creatinine level > or = 2 mg/dl on admission, and a previous history of IE, were independent predictors for in-hospital mortality in IE.

Ascending aortic pressure-derived indices are associated with the presence and severity of aortic stenosis.

BACKGROUND: Almost the same pathophysiological mechanism has been suggested for both atherosclerosis and calcific aortic stenosis (AS). In this study, we examined any association between ascending aortic pressure-derived indices and hemodynamic characteristics of calcific AS. METHODS: A total of 90 patients were studied (26 males, 64 females; mean age: 64.4 +/- 11.3 years). The study population consisted of two groups: AS and a control group. Both groups were well matched. Ascending aortic pressure-derived indices were obtained from all patients via catheterization. RESULTS: Two groups were well matched according to demographic characteristics. Aortic pulse/FPPs (fractional pulse pressure = aortic pulse pressure/ aortic mean pressure), and PI (pulsatility index = aortic pulse pressure/aortic diastolic pressure) were significantly higher in patients with AS than in those without. Mean aortic mean gradient had significant positive correlation with aortic diastolic pressure, FPP and PI. The multiple-adjusted odds ratios of the risk of AS was 4.51 (95% CI 1.63-12.48) and 4.34 (95% CI 1.59-11.88) for the higher aortic FPP and PI levels compared with lower levels, respectively. CONCLUSION: Ascending aortic pressure-derived indices were significantly and independently associated with the presence and severity of calcific AS. This confirms the participation of blood pressure in the pathogenesis of AS.

[Stabilization of a dislocated coronary sinus electrode by coronary stenting during resynchronization therapy]. / Kardiyak resenkronizasyon tedavisinde yerinden oynayan koroner sinüs elektrodunun stent ile sabitlenmesi.

Cardiac resynchronization therapy (CRT) is an effective treatment in patients with severe refractory heart failure combined with intraventricular conduction disease, improving quality of life and decreasing mortality. In CRT, pacing of the left ventricle is accomplished by a coronary sinus (CS) electrode. The main challenge for this technique is to achieve and maintain an optimal lead position so that no dislocation occurs. Cardiac resynchronization therapy was planned in a 66-year-old male patient with NYHA (New York Heart Association) class 3-4 symptoms and left bundle branch block. After two dislocations of the pacing lead from the posterolateral CS, the lead was implanted in the middle cardiac vein and stabilized by coronary stenting. During a six-month follow-up, no further dislocation occurred and pacing parameters were normal.