Ectopic Origin of Coronary Arteries Diagnozed by Coronary Angiography.

INTRODUCTION: Anomalous origin of coronary arteries from opposite sinus of Valsalva is rare finding. The incidence of anomalous origination of the left coronary artery from right sinus is 0.15% and the right coronary artery from the left sinus is 0.92%. The ectopic origin of left coronary artery or right coronary artery from opposite sinus depending on pathways and considering atherosclerotic changes are manifested with different clinical significance. CASE REPORT: We report two cases, the first case the coronary angiography showed the left coronary artery arising from the right coronary sinus, presenting with proximally and distally stenosed left anterior descending artery (LAD), associated with medial and distal stenosed right coronary artery (RCA). The second case the coronary angiography revealed the right coronary artery arising from the left coronary sinus, associated with tortuous medial and distal segments of left anterior descending artery (LAD), without atherosclerotic changes. The first case successfully underwent treatment procedures based on guidelines for revascularization. CONCLUSION: The coronary angiography of patients with coronary ischemia determines atherosclerotic disease with possibility of the presence of coronary artery anomalies that in cases with ectopic origin from opposite sinus continues to exist as a challenge during treatment in interventional cardiology.

The Relation Between Depressive Symptoms and Self-Care in Patients with Diabetes Mellitus Type 2 in Kosovo.

BACKGROUND: The depression is a significant problem in patients with diabetes. This research is the first of it's kind conducted in the Republic of Kosovo to determine the prevalence of depression diagnosed in people with diabetes mellitus type 2 (DMT2) and interrelation between depressive symptoms and behavior of diabetes self-care (glucose monitoring, exercise, diet, and self- health care). METHODS: Research was conducted in the University Clinical Center of Kosovo (UCCK), in Pristine. The sample consisted of 200 individuals. Data collection was done through structured questionnaires. HANDS (Harvard Department of Psychiatry / National Depression Screening Day Scale) questionnaire was used to assess depressive symptoms and DSMQ (The Diabetes Self-Management Questionnaire) was used to assess self-care behavior. Data analysis was run through SSPS program, version 21. RESULTS: The results showed that the prevalence of depression in diabetic patients was 66.5% in Kosovo. Being a woman, a resident of rural areas or with low level of education, there were significant predictors and were associated with increased chance of developing the symptoms of major depression. Significant relations were found between major depression and physical activity (p<0.05). While between major depression and management of blood glucose level, dietary control and self health care, no significant correlation was found. CONCLUSION: This paper concluded the involvement of psychological aspect in health care plan for diabetics, in order to reduce the number of individuals affected by depression, to diagnose and to treat these individuals for a better quality of life.

Anomalous Origin of Left Circumflex Artery.

INTRODUCTION: The coronary anatomic variation of the left circumflex artery (LCx) is considered as the most common anatomic variation with a separate ostium from the right sinus, and very unusual variation as a proximal branch of right coronary artery (RCA). CASE REPORT: We report two cases, the first case is a 64-year-old man with chest pain and with history of hypertension, obesity, dyslipidemia and current smoker, and the second case is a 67-year-old who presented to the emergency department with chest pain and with a past medical history of arterial hypertension and type 2 diabetes mellitus. In the coronarography of the first case is detected an ectopic left circumflex coronary artery from the right coronary sinus with stenotic changes in RCA and LCx. The second case in the coronary angiography revealed an ectopic left circumflex coronary artery from the proximal part of the right coronary artery with stenotic changes in LAD, RCA and LCx. Based on guidelines for revascularization our patients successfully underwent treatment procedures. We present two cases that because of the atherosclerotic coronary artery disease leads to the need of coronarography find out the presence of coronary artery anomalies. CONCLUSION: During the coronarography we should think about coronary artery anomaly or missing artery knowing that type of these anomalies, considering that may be a contributing factor in the development of the atherosclerosis determines the method of the treatment.

Left ventricular diastolic dysfunction in asymptomatic type 2 diabetic patients: detection and evaluation by tissue Doppler imaging.

CONFLICT OF INTEREST: NONE DECLARED The aim of the study was detection of diastolic dysfunction of myocardium with Tissue Doppler Imaging (TDI) in asymptomatic type 2 diabetic patients, in five years duration of disease, and normal cardiac function on conventional echocardiography (CE), according to the performance showed on exercise stress test. MATERIAL AND METHODS: We studied 300 patients, of them 150 patients with non-obese, normotensive, uncomplicated type 2 diabetes, in five years duration of disease and 150 healthy control subjects. Of all patients, 100 with type 2 diabetes, and 100 patients from the control group underwent exercise test on a treadmill. All participants underwent both CE and TDI echocardiography. With TDI, lateral E' peak velocity, atrial velocity (A'), their ratio (E'/A') and systolic velocity (S') were measured. Diastolic dysfunction was diagnosed by tissue Doppler imaging, and the following criterion was met: E'/A' ratio <1. Cardiac function with CE was without significant features in the two groups. RESULTS AND DISCUSSION: Using TDI interrogation, diabetic subjects showed a lower E' velocity (10,75±1,2 vs. 14±3 cm/s, p<0,001), an increased A' velocity (10,65±1,8 vs. 11±3 cm/s, p<0,02), and a reduced E/A ratio (0,82±0,04 vs. 1,17±1,4, p<0,001), S (8.92±3,80 vs. 9,30±3.30 cm/sec); E/A (1,17±0.55, p<0,01). In diabetic patients, after the exercise stress test performance, the myocardial velocity increase is registered for wave E'=1,27 cm/sec (12,01%), for wave A'=1,7 cm/sec (15,9%), reduced ratio E'/A' (0.89±0,1 cm/sec 9,0%) and S'=1,3 cm/sec (14,77%). Whereas, mean myocardial velocity values in examined control group after the exercise stress test were higher as follows: E'=2,7 cm/sec (19%), A'=2,1 cm/sec (14%), E'/A'=0,8 cm/sec (12%), and S'=2,7 cm/sec (18%). Myocardial diastolic dysfunction due to reduced exercise tolerance can be evidenced by TDI in type 2 diabetic subjects, even in the presence of a normal cardiac function with CE and symptom free diabetic patients in rest. Therefore, our findings could justify the use of Tissue Doppler imaging for diastolic function assessment in diabetics with otherwise non significant features on CE.

Aortic Compliance and Stiffness Among Severe Longstanding Hypertensive and Non-hypertensive.

INTRODUCTION: Abnormal aortic function in hypertension is generally attributed to accelerated breakdown of elastin in the aorta, leading to dilatation of the lumen and stiffening of the wall as elastin is replaced with stiffer collagen. Aortic stiffness is an independent predictor of cardiovascular risk and all-cause and cardiovascular mortality. Vascular stiffening can activate endothelium which in turn may promote atherogenesis. Modulation of arterial stiffness has been shown to be successfully managed via changes in lifestyle and put under control of hypertension pharmacologically with antihypertensive drugs and statins. METHODS: Hundred and forty four patients have been enrolled in this study. They have been divided in two groups, with hypertension and group of control. Groups were with no age difference. RESULTS: Group with hypertension were with reduced aortic strain, distensibility (compliance) and have higher stiffness than control group; GrHTA =9.3 compared to GC=5.4. After successful treatment of hypertension with antihypertensives and statins, for two years, these parameters showed improvement, but still remain out of normal range compared to control group; 7.6 vs. 5.38. CONCLUSIONS: Hypertensive patients have reduced aortic elasticity and increased stiffness which can be stopped and improved after treatment with antihypertensive and statin.

Comparison of two and three dimensional transthoracic versus transesophageal echocardiography in evaluation of anatomy and pathology of left atrial apendage.

OBJECTIVE: Our objective was the comparison of combined utility of two-dimensional (2D) transthoracic echocardiography (TTE) and three-dimensional (3D) TTE versus 2D and 3D transesophageal echocardiography (TEE) in evaluation of anatomy of the left atrium appendage (LAA) and for clot formation in LAA. BACKGROUND: 2DTEE as semi-invasive method has been for a long time used to visualize the LAA. Improved echocardiography technology has increasingly improved visualization of LAA by 2DTTE and 3DTTE in many patients and decreased the need for TEE performance. METHODS: We compared combined 2DTTE and 3DTTE with 2DTEE and 3DTEE in evaluating the LAA for anatomical features and thrombus. Eighty-six patients underwent 2DTTE, 3DTTE, 2DTEE and 3DTEE. RESULTS: LAA could be visualized in all patients. 31 % of patients had one lobe, 43% had 2 lobes and 26% had > 2 lobes. Of 86 patients studied, 79 had no thrombus and 7 had thrombus in the LAA by all modalities. Six patients, 3 with atrial fibrillation (AF), and 4 in sinus rhythm (SR) had a suspected thrombus by 2DTEE. Only in one patient 3DTEE cropping has been needed to clearly show thrombus which was suspected in short axis view on 2DTEE as rounded echo dense mass. CONCLUSIONS: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LAA anatomy and pathology in terms of thrombus. Only in inappropriate (obese) patients 2TTE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.

Prolonged spasm of the left anterior descending coronary artery.

Coronary artery spasm is one of the well-known causes of anginal chest pain. We presented the case of prolonged spasm of the left anterior descending coronary artery which happened during coronary angiography leading to pulse less state and low blood pressure with syncope and appearing of ventricular fibrillation on ECG. During one hour of successful cardiopulmonary resuscitation, the patient had again normal pulse and blood pressure. Coronary angiography performed immediately after DC's showed normal coronary angiogram. After two days the patient left the hospital without brain disorders.

Pleiotropic and Lipid-lowering Effects of Statins in Hypertension.

BACKGROUND: Data on the lowering effects of statins in hypertensive patients have been mixed and highly controversial. Some studies shows reductions effects of statins in blood pressure, whereas others do not. The evidence in the literature on the effects of statins on blood pressure raises the possibility that statins may directly lower blood pressure in addition to reduce cholesterol levels-pleiotropic effects of statins. AIM OF THE STUDY: The role of statins as additional treatment in patients with severe hypertension and advanced aortic atherosclerotic plaques. Methods. We enrolled 62 patients. Study has been approved by Committee of Ethics and patients signed a Term of Free Informed Consent. All patients were studied with transoesophageal echocardiography at baseline and 12 months after enrolment. Inclusion criteria were severe hypertension and presence of aortic atherosclerotic plaques. Patients have been divided into two groups; group A (treated with antihypertenives and statins) and group B (treated, just with antihypertensives). RESULTS: Twenty patients, of totally 38, from group A (20/38 or 52.6%) had significantly plaque reduction. One patient of totally 24 (1/24 or 4.1% ) from group B had significantly atherosclerotic plaque reduction. Difference of plaques reduction between two groups was highly significant. Regarding blood pressure levels, statins users had significantly reduction on systolic and diastolic blood pressure compared to statins nonusers. CONCLUSION: Hypertensive patients with presence of AA plaques treated with antihypertensives and statins have more BP reduction compared will hypertensive patients treated with antihypertensives alone.

The importance of echocardiographic evaluation of pericardial effusion associated with mitral valve pseudoprolapse in patients with chronic renal failure.

To evaluate the clinical course of pericarditis in patients with chronic kidney disease (CKD), we studied echocardiography in 64 CKD patients and subdivided them into four groups according to their CKD condition and presence of effusion: 14 (22%) patients with pericardial effusion that formed during conservative treatment of CKD patients, 12 (19%) patients who developed the effusion while on regular hemodialysis, 31 (48%) CKD patients without pericardial effusion, and seven (11%) CKD patients with minimal effusion. In addition, the patients were then re- subdivided according to the amount of pericardial effusion into those with small amount, up to 1 cm echo- free space (EFS) (17 (27%) patients); with medium size pericardial effusion (9 (14%) patients); with large amount of pericardial effusion, above 2 cm (four (6%) patients); and with thickened pericardium (4 (6%) patients), three (5%) of whom were without pericardial effusion and one (2%) was with minimal effusion. Nine (15%) patients revealed signs of mitral valve prolapse. The presence of EFS between the posterior epicardium and pericardium during the entire cardiac cycle was found in 31 (48%) patients. We conclude that the presence of a positive EFS without other clinical symptoms does not confirm with certainty the presence of pericarditis in CKD patients.

Common atrium associated with polydactily and dwarfism in middle age male patient.

Polydactyly associated with dwarfism may serve as a hint for the presence of additional congenital cardiac abnormalities, thus rousing the demand for a detailed cardiac and genetic investigation. In our case, echocardiography findings led to the diagnosis of most likely Ellis-van Creveld syndrome. We may conclude that prenatal diagnosis of the syndrome can be readily achieved by fetoscopy, fetal echocardiography, and molecular genetic testing by amniocentesis or DNA extracted from chorionic villus samples. Prenatal diagnosis can also be established using mutation analysis of EVC gene from fetal DNA. These cases emphasis the importance of fetal examination for accurate diagnosis of rare syndromes. Education of the general public, especially parents, on congenital anomalies as well as improvement of medical and diagnostic facilities is therefore suggested, if not demanded.

Follow-up of acute aortic dissection.

INTRODUCTION: Aortic dissection is a tear in the wall of the aorta. It is a medical emergency. If left untreated the mortality rate is extremely high. Aortic dissection is divided into two types, A and B. Primary, because of low suspicion the diagnosis can delay. The natural history is poorly understood. OBJECTIVES: Our objectives were to improve diagnosis of aortic dissection. To encourage use of trans esophageal echo cardiography in emergency room. To clarify the role of prompt treatment in prognosis of aortic dissection. METHODS: This study was approved by the Committee of Ethics. All of the patients signed a informed consent. Clinical evaluation was performed by expert cardiologists, using different modalities. A complete medical history and physical examination were performed. The follow-up time of patients was 24 months. RESULTS: Eleven patients were included in this study. Male/female ratio was 2.7:1. Type A was present in 7 patients, hypertension in 9. All patients were symptomatic. Three patients died, two in the emergency center, one after surgery. Surgery was performed in five patients, all with type A dissection. Four survived patients after operation and all patients with type B dissection survived follow-up time of 24 months. CONCLUSION: Most crucial step in aortic dissection diagnosis remain clinical suspicion. It should be confirmed rapidly since it is lifesaving. We want to emphasize that the trans esophageal echo cardiography is very useful exam to make the diagnosis which is the key for correct treatment and for follow-up. It must be widely available in the emergency centre.

Multiplane transesophageal echocardiography for multiclinical dilemmas.

INTRODUCTION: Transesophageal echocardiography was introduced 4 decades ago. Its use have had very limited clinical indication. Now it has become very useful clinical tool. Indications for its use are almost as indications for transthoracic echocardiography, especially to assess deeper cardiovascular structures. Transesophageal echocardiography is semi-invasive examination with small number of complications. AIM OF THE STUDY: To determine usefulness of transesophageal echocardiography in various cardiac conditions based in our experience. Also to encourage use of transesophageal echocardiography as reliable examination. METHODS: All of the patients signed a Term of Free Informed Consent, approved from Ethics Committee. We enrolled 425 patients who have done TEE in last 5 years (2006-2010) by authors. Medical history and Clinical evaluation was carefully performed by expert cardiologists. Procedures were performed in two different centers using machines, PHILIPS iE33 and Siemens accuson CV 70, with equipment attached to a multi frequency 2.5 to 3.5 MHz for TTE and 7.0 MHz for TEE multiplane transducer. TEE were performed and images were obtained according to the standard recommandations. RESULTS: The results were analyzed by a standard method of descriptive statistics using Pivot Table of Excel Office 2007. Results. We have analyzed 425 transesophageal echocardiography . The examination of the thoracic aorta in severe hypertension patients was conducted in 96 cases; atrial fibrillation in 118; aortic dissection 49 cases, aortic stenosis was evaluated in 28 cases; finding of source of emboli 36 cases; suspicion for aneurysm of the thoracic aorta in 14 cases, 11 cases with suspected endocarditis; the type of intervention for mitral valve was evaluated in 28 cases. Interatrial septum abnormalities 37 cases; and miscellaneous 18 cases. No minor or mayor complications happened. CONCLUSION: [corrected] Transesophageal echocardiography can elucidate many dubious serious conditions immediately after it is performed. So, we think that transesophageal echocardiography is very useful tool in everyday clinical use, almost without complications if it is done correctly.

Treatment benefits on metabolic syndrome with diet and physical activity.

The research has included 422 patients aged between 25 to 60, of whom 341 were men and 81 women. The purpose of research was to determine impact of diet and physical activity in the treatment of metabolic syndrome during the six month period. Processing of results through descriptive and discriminative analysis have indicated that 6 month treatment with diet and physical activity have had an impact in the: waistline decrease by 6.05 cm or 5.50% among males, and 4.92 cm or 5.10% among females; body mass index (BMI) decrease by 1.78 or 6.20% among males, and 2.3 or 8.16% among females; decrease of blood triglycerides levels by 0.35 mmol/L or 16.28% among males, and 0.27 mmol/L or 13.30% among females; increase of blood cholesterol HDL-C by 0.48 mmol/L or 34.78% among males, and 0.06 mmol/L or 4.28% among females; systolic arterial pressure decreased by 15 mmHg or 10.18%, and diastolic blood pressure by 8.74 mmHg or 9.47% among males, and systolic arterial pressure decreased by 7.39 mmHg or 5.17%, and diastolic blood pressure decreased by 5.18 mmHg or 5.75% among females; the level of blood glucose decreased by 0.45 mmol/L or 7.04% among males, and by 0.64 mmol/L or 9.92% decreased among females. The results show that physical exercise and diet are important factors in reducing the values symptoms of metabolic syndrome. In order to improve symptoms of metabolic syndrome, it is necessary to keep on with healthy diet and physical exercise that means the change of lifestyle.