Multivessel coronary-cameral fistulas associated with ventricular fibrillation: an unusual case.

Coronary-cameral fistula (CCF) is a rare connection between a coronary artery and a chamber of the heart. It most often derives from the right coronary artery and drains into the right ventricle. CCF originating from all 3 major coronary vessels and draining into the left heart is an extremely rare coronary artery malformation. A 47-yearold-man who was admitted to the clinic with angina pectoris and positive cardiac markers suddenly developed ventricular fibrillation (VF) while being prepared for coronary catheterization. He was successfully defibrillated and sinus rhythm was restored. The coronary angiography revealed normal epicardial coronary arteries with multiple diffuse fistulas originating from both the right and left coronary artery systems, terminating in the left ventricle. This is a very rare case of multiple CCFs originating from the epicardial coronary arteries and associated with myocardial ischemia and VF.

Major depressive disorder is associated with fragmented QRS.

Objective There is a close link between major depressive disorder (MDD) and cardiovascular disease (CVD). Increasing oxidative stress, changes in hypothalamic-pituitary-adrenal axis and platelet clotting cascade may lead to subclinical myocardial damage in MDD patients without overt CVD. The aim of the study was to investigate whether MDD is associated with fragmented QRS (fQRS) on electrocardiogram (ECG) which may reflect myocardial fibrosis/scarring and ischaemia. Methods and results A total of 66 MDD patients without overt CVD and 35 age- and sex-matched control subjects were enrolled in this study. Twelve-lead surface ECGs were analysed for the presence of fQRS and echocardiographic examination was performed for each individual. Multivariate logistic regression analysis was used to assess the relationship between MDD and fQRS. The baseline characteristics in terms of age, gender, body mass index and cardiovascular risk factors were comparable in the groups (all P values >0.05). Left ventricular ejection fraction, left ventricular wall thickness and diastolic blood pressure were also similar in the two groups. The presence of fQRS was more prevalent (P < 0.001) and SBP values (P = 0.007) were higher in patients with MDD compared to controls. Moreover, multivariate binary logistic regression analysis indicated the recurrent MDD as the only independent predictor of fQRS on ECG (beta =0.196, 95% CI 0.046 - 0.827, P = 0.014). Conclusion The presence of fQRS on the ECG is associated with MDD, and may be a beneficial tool for detecting subclinical cardiac damage in this population.

Arterial stiffness is associated with left ventricular dysfunction in patients with rheumatoid arthritis.

Arterial stiffness (AS) has a detrimental effect on cardiovascular system particularly on left ventricle (LV). The aim of the study was to evaluate the impact of AS on LV functions in patients with rheumatoid arthritis (RA). Forty patients with RA and 25 age-sex matched control subjects (mean age 48.5 ± 6.3 vs. 45.1 ± 6.9 years, respectively, p = 0.06) were enrolled in study. AS was assessed by carotid-femoral pulse wave velocity (CF-PWV) and heart rate corrected augmentation index (AIx@75) measured by applanation tonometry (SphygmoCor). LV function was evaluated using tissue Doppler-derived myocardial performance index (MPI) from lateral mitral annulus. CF-PWV (28.3 ± 10.3 vs. 21.8 ± 9.3 m/s, p = 0.03), AIx@75 (10.2 ± 2.3 vs. 9.2 ± 1, %, p = 0.01) and MPI (0.46 ± 0.12 vs. 0.36 ± 0.1, p < 0.001) were significantly higher in patients with RA than in controls. LV MPI was found to be significantly positive correlated with CF-PWV, AIx@75, and ESR (r = 0.360, p = 0.005; r = 0.334, p = 0.009; r = 0.293, p = 0.023, respectively). Arterial stiffness parameters including CF-PWV and AIx@75 are associated with subclinical left ventricular dysfunction in patients with RA.

Fragmented QRS Is Associated with Improved Predictive Value of Exercise Treadmill Testing in Patients with Intermediate Pretest Likelihood of Significant Coronary Artery Disease.

BACKGROUND: The predictive value of exercise treadmill testing (ETT) remains inadequate in diagnosing patients with suspected coronary artery disease (CAD) and needs to be improved. OBJECTIVE: The aim of this study was to investigate whether the presence of FQRS on 12-lead ECG would increase the PPV of ETT in patients with an intermediate likelihood of CAD. METHODS: fQRS, defined as the presence of notched R or S waves without accompanying typical bundle branch block or the existence of an additional wave-like RSR' pattern in the original QRS complex (with a duration of <120 ms), was assessed in 95 patients with positive ETT. Coronary angiogram (CA) was performed in all patients, divided into two groups as the significant CAD group and nonsignificant CAD group according to coronary artery lesions. The differences between the groups in terms of the presence of fQRS and clinical characteristics were investigated. RESULTS: The mean age of patients was 51.3 ± 11.3 years, and 74 of them were males (77.9%). FQRS was present in 47 (49.5%) patients, and significant CAD was demonstrated in 51 subjects (53.7%) among the enrolled subjects. fQRS was more prevalent in the significant CAD group compared to nonsignificant CAD group (P < 0.001). The presence of FQRS increased the PPV of positive ETT from 53.7% to 85.1%. In addition, FQRS was associated with the increased risk of significant CAD in multivariate analysis (OR = 2.839, P < 0.001). CONCLUSION: In clinical practice, the presence of fQRS in patients with positive ETT may support clinicians during the decision-making process with regard to the referral for a coronary angiography.

Radiotherapy Induces Development of Fragmented QRS in Patients with Breast Cancer.

BACKGROUND: Myocardial fibrosis is a well-known side effect of radiotherapy. Fragmented QRS (fQRS) has been shown to be a marker of myocardial fibrosis. We postulated that radiotherapy induces development of fQRS in breast cancer patients. PATIENTS AND METHODS: Breast cancer patients receiving locoregional radiotherapy were enrolled. Patients who had fQRS on electrocardiography (ECG) before radiotherapy were excluded. All patients were revaluated for the development of fQRS at 1-year follow-up. An age-matched healthy group served as controls. RESULTS: A total of 52 breast cancer patients receiving locoregional radiotherapy were included (median age 49 years, interquartile range (IQR) 13). Of these, 19 (37%) had developed fQRS at 1-year follow-up. Compared with the control group, prevalence of fQRS was significantly higher in the irradiated group (37 vs. 12%; p < 0.002). Median total cardiac radiation dose was significantly higher in patients who had developed fQRS (5 Gy, IQR 5.2 vs. 1.7 Gy, IQR 4.4; p = 0.003). Cardiac radiation dose, entered either as a continuous variable (odds ratio (OR) 1.35, 95% confidence interval (CI) 104-1.74) or as a dichotomized variable (≥ 2.2 Gy, OR 6.48, 95% CI 1.47-28.61), was independently associated with the development of fQRS at 1-year follow-up. CONCLUSION: Radiotherapy for breast cancer induces development of fQRS on ECG. Cardiac radiation dose is independently associated with the development of fQRS.

Evaluation of serum sTWEAK and sCD163 levels in patients with acute and chronic coronary artery disease.

BACKGROUND: Recent studies have suggested soluble tumor necrotizing factor-like weak inducer of apoptosis (sTWEAK) and sCD163 may be a potential cardiovascular biomarker. We aimed to evaluate sTWEAK and sCD163 levels and predictive values in patients with chronic coronary artery disease (CAD) and acute coronary syndrome (ACS). METHODS: Two hundred fourteen angiography-made patients were enrolled in the study and divided into 3 groups: 30 controls with normal angiograms, 99 patients with ACS, 85 patients with chronic CAD. sTWEAK, sCD163 and CRP levels were measured. Receivers operating characteristic (ROC) curve analysis were performed to determine the predictive values of sTWEAK and sCD163 levels and the sCD163/sTWEAK ratio. Gensini scores were used to assess severity of CAD. RESULTS: sTWEAK levels in chronic CAD and ACS patients were lower compared to the control group (P<0.0001). sCD163 levels (P<0.0001) and the sCD163/sTWEAK ratio (P<0.0001) were higher in the ACS patients compared to the control and chronic CAD patients. ROC analysis revealed low sTWEAK level and high sCD163/sTWEAK ratio predicted chronic CAD, and low sTWEAK, high sCD163, CRP levels and sCD163/sTWEAK ratio predicted ACS. According to ROC analyses, significance of sTWEAK levels for chronic CAD was more marked compared to ACS (P<0.0001 vs P=0.001) and significance of sCD163/sTWEAK ratio was greater than sTWEAK for ACS (P<0.0001 vs P=0.001). These parameters didn't correlate with severity of disease, obtained gensini scoring, in chronic CAD. CONCLUSIONS: It was concluded thatsTWEAK level may be a diagnostic marker of especially chronic CAD, sCD163 level of ACS, and the sCD163/sTWEAK ratio of both chronic CAD and ACS.

Assessment of total cardiac repolarization's spatial distribution among patients with aortic sclerosis.

OBJECTIVE: To measure the Tp-e value, which shows the spatial distribution of cardiac repolarization and is defined as a possible predictor for ventricular arrhythmia among patients with aortic sclerosis (AS), and to compare this parameter's length to QTc length within the same population. METHOD: 60 patients that have been diagnosed with AS have been prospectively included in this study. RESULTS: 60 AS and 64 control patients were evaluated as part of the study. The median age, prevalence for hypertension and diabetes, baseline medications and laboratory results of the groups were similar. The Electrocardiographic QT length of both groups were found similar. In the AS group Tp-e tangent and Tp-e tail values were more longer than control group (P < 0.001). Tp-e tangent index and Tp-e tail index values were also statistically higher among AS patients when compared to the control group. (P < 0.001). CONCLUSION: Our study showed that Tp-e durations had increased in AS patients with no structural coronary heart disease. AS causes local degeneration on the aortic root and also has a negative effect on the total cardiac spatial repolarization.

Relationship between epicardial fat tissue and left ventricular synchronicity: An observational study.

OBJECTIVE: Left ventricular (LV) systolic synchrony is defined as simultaneous activation of corresponding cardiac segments. Impaired synchrony has some adverse cardiovascular effects, such as LV dysfunction and impaired prognosis. Epicardial fat tissue (EFT) is visceral fat around the heart. Increased EFT thickness is associated with some disorders, such as LV dysfunction and hypertrophy, which play a role in the impairment of LV synchrony. However, the relationship between EFT and LV systolic synchrony has never been assessed. Thus, we aimed to evaluate the possible relationship between EFT and LV synchrony in this study. METHODS: The study population consisted of 55 consecutive patients (mean age 46.4±13.4 years, 32 female) without bundle branch block (BBB). EFT and LV systolic synchrony were evaluated by transthoracic echocardiography using 2D and tissue Doppler imaging. Maximal difference (Ts-6) and standard deviation (Ts-SD-6) of time to peak systolic (Ts) myocardial tissue velocity obtained from 6 LV basal segments were used to assess LV synchrony. Multiple regression analysis was used to detect the independently related factors to LV synchrony. RESULTS: The mean values of EFT thickness, Ts-6, and Ts-SD-6 were found to be 2.7±1.6 mm (ranging from 1-7 mm), 20.1±14.2 msec, and 7.7±5.6, respectively. EFT thickness also was independently associated with Ts-6 (ß=0.332, p=0.01) and Ts-SD-6 (ß=0.286, p=0.04). CONCLUSION: EFT thickness is associated with LV systolic synchrony in patients without BBB.

The relationship between epicardial fat tissue thickness and frequent ventricular premature beats.

BACKGROUND: Ventricular premature beats (VPBs) are one of the most common rhythm abnormalities. Structural heart diseases such as myocardial hypertrophy and left ventricular dysfunction are associated with VPBs. However, the exact mechanism of VPBs in patients without structural heart disease has not been revealed yet. Epicardial fat tissue (EFT) is a visceral fat around the heart. Increased EFT thickness is associated with myocardial structural and ultrastructural myocardial abnormalities, which may play a role in the development of VPBs. AIMS: To evaluate the possible relationship between EFT thickness and frequent VPBs. METHODS AND RESULTS: The study population consisted of 50 patients with VPBs and 50 control subjects. Frequent VPBs were defined as the presence of more than 10 beats per hour assessed by 24-h Holter electrocardiography monitoring. EFT thickness was measured by transthoracic echocardiography. Multivariable logistic regression analysis was used to assess factors related with frequent VPBs. Baseline demographic and biochemical features including age, gender, and rates of hypertension and diabetes mellitus were similar in both groups. EFT thickness was significantly higher in patients with frequent VPBs than in controls (3.3 ± 1.3 mm vs. 2.2 ± 0.8 mm, p < 0.001). In multivariable logistic regression analysis, EFT thickness was independently associated with VPB frequency (B = 1.030, OR = 2.802, p < 0.001). CONCLUSIONS: Patients with frequent VPBs had increased EFT thickness compared to control subjects. EFT thickness was independently associated with frequent VPBs.

Left ventricular synchronicity is impaired in patients with active acromegaly.

Acromegaly is associated with a variety of cardiovascular disturbances such as left ventricular hypertrophy, diastolic cardiac dysfunction, and hypertension. Left ventricular (LV) dyssynchrony means the impairment of synchronicity and is defined as the loss of the simultaneous peak contraction of corresponding cardiac segments. The objective of this study was to investigate whether acromegalic patients have left ventricular dyssynchrony. Dyssynchrony was evaluated in 30 patients with active acromegaly and 30 controls. All the patients and controls were subjected to a tissue synchronization imaging. The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-mid-segmental model was measured on ejection phase TSI images and four TSI parameters of systolic dyssynchrony were computed. All TSI parameters of LV dyssynchrony increased in patients with acromegaly compared to the controls: the standard deviation (SD) of the 12 LV segments Ts (43.5 ± 13.5 vs 26.2 ± 12.5, p < 0.001); the maximal difference in Ts between any 2 of the 12 LV segments (133.3 ± 38 vs 84.6 ± 37.6, p < 0.001); the SD of the 6 basal LV segments (41.1 ± 15.9 vs 25.4 ± 14.8, p = 0.001); and the maximal difference in Ts between any 2 of the 6 basal LV segments (102.6 ± 37.5 vs 65.2 ± 36.9, p = 0.001). In addition, there were significant relationships between the levels of growth hormone/insulin-like growth factor-1 and Ts-SD-12. LV synchronicity has been impaired in patients with acromegaly. Left ventricular dyssynchrony is associated with disease activity and it may contribute to the harmful cardiovascular effects of acromegaly.