The evaluation of subcutaneous and visceral adipose tissue changes by computed tomography in coronavirus disease 2019 and comparison with quantitative analysis of lung involvement.

BACKGROUND: This study aims to reveal the relationship between lung involvement and visceral adipose tissue changes between chest-computed tomography (CT) scans taken in short intervals in COVID-19 patients. METHODS: The retrospective study included 52 patients who tested positive for SARS-CoV-2. All patients had two chest CT exams. Lung involvement measurements were calculated by using an artificial intelligence tool. Visceral and subcutaneous fat tissue was measured at the level of the first lumbar vertebra on chest CT. Additionally, demographic and laboratory data were collected. RESULTS: 52 patients were included (36.5 % female, mean age 50). Visceral fat area and visceral fat thickness changes were significantly positive predictors of total lung involvement changes (p=0.033, p=0.00024). Subcutaneous fat area and subcutaneous fat thickness changes were not associated with lung involvement change (p>0.05). CRP, IL-6, d-dimer, and ferritin levels were higher in patients who need intensive care units. CONCLUSION: Visceral adipose tissue changes may indicate that it can have a role as a reservoir of virus involvement.

Asymptomatic Tricuspid Stenosis Following a Complex Lead Extraction Procedure.

The number of transvenous extraction procedures for leads of intracardiac rhythm devices increased recently and the most common reason for lead extraction is device infection. In some cases, combined use of two different techniques is necessary. Long-term results of this approach are not clear. In this case report, we present a patient with biventricular implantable cardioverter defibrillator who underwent percutaneous hardware removal due to recurrent pacemaker pocket infections. Mechanical dilator sheath removal and Needle's Eye Snare were used in the same patient. Although asymptomatic, tricuspid stenosis was detected three years after the operation.

Effect of left ventricular diastolic dysfunction on left atrial appendage function and thrombotic potential in nonvalvular atrial fibrillation.

OBJECTIVE: We aimed to investigate effects of left ventricular diastolic dysfunction on left atrial appendage functions, spontaneous echo contrast and thrombus formation in patients with nonvalvular atrial fibrillation. METHODS: In 58 patients with chronic nonvalvular atrial fibrilation and preserved left ventricular systolic function, left atrial appendage functions, left atrial spontaneous echo contrast grading and left ventricular diastolic functions were evaluated using transthoracic and transoesophageal echocardiogram. Patients divided in two groups: Group D (n=30): Patients with diastolic dysfunction, Group N (n=28): Patients without diastolic dysfunction. Categorical variables in two groups were evaluated with Pearson's chi-square or Fisher's exact test. The significance of the lineer correlation between the degree of spontaneous echo contrast (SEC) and clinical measurements was evaluated with Spearman's correlation analysis. RESULTS: Peak pulmonary vein D velocity of the Group D was significantly higher than the Group N (p=0.006). However, left atrial appendage emptying velocity, left atrial appendage lateral wall velocity, peak pulmonary vein S, pulmonary vein S/D ratio were found to be significantly lower in Group D (p=0.028, p<0.001, p<0.001; p<0.001). Statistically significant negative correlation was found between SEC in left atrium and left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities respectively (r=-0.438, r=-0.328, r=-0.233, r=-0.447). Left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities were significantly lower in SEC 2-3-4 than SEC 1 (p=0.003, p=0.029, p<0.001, p=0.002). CONCLUSION: In patients with nonvalvular atrial fibrillation and preserved left ventricular ejection fraction, left atrial appendage functions are decreased in patients with left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction may constitute a potential risk for formation of thrombus and stroke.

Multidetector computed tomographic anatomy of the coronary sinus in patients with supraventricular reentrant tachycardia.

BACKGROUND: In a number of previous studies it has been observed that coronary sinus (CS) ostium was larger and cannulation was easier in patients with atrioventricular nodal reentrant tachycardia (AVNRT). AIM: To investigate the size and morphology of CS in AVNRT patients and compare them to those of atrioventricular reentrant tachycardia (AVRT) patients and a control group using multidetector computed tomography (MDCT), which is a non-invasive technique. METHODS: Eighteen consecutive patients with AVNRT who were scheduled for catheter ablation in our institution constituted the study population. Sixteen patients with AVRT and 16 patients without supraventricular arrhythmia who underwent MDCT for other indications comprised the control group. A conventional transthoracic echocardiography was performed to all patients. The diameter of the CS at ostium as well as at 5, 10, and 15 mm inside the CS were measured on MDCT images. The CS was also categorised according to its morphology, as to whether it had a windsock shape or a tubular shape. RESULTS: The AVNRT, AVRT and control groups were similar with regard to age, gender, body surface area and echocardiographic parameters. The size of the CS ostium was 10.9 ± 3.0, 11.1 ± 3.9 and 12.5 ± 3.6 mm for the AVNRT, AVRT and control groups, respectively (p = 0.393). There was no significant difference in the size of the CS from the ostium until 15 mm into the CS between the AVNRT, AVRT and control groups. The number of patients with windsock or tubular CS morphology were also similar between the three groups. CONCLUSIONS: Contrary to previous reports, the CS size and morphology of patients with AVNRT did not differ from that of AVRT or control patients.

Arrhythmias during and after zoledronic acid infusion patients with bone metastasis.

Zoledronic acid (ZA) is one of the important bisphosphonates which is widely used in bone metastatic cancer and osteoporotic patients. In a few studies, it has been reported that treatment with bisphosphonates was associated with an increased risk of atrial fibrillation. We aimed to evaluate the arrhythmias that developed during and immediately after infusion of the ZA. Fifty-two bone metastatic patients were included in the study group. All patients had 24-h Holter monitorization during the first dose ZA infusion day. All of the patients had 4-h basal cardiac rhythm records before ZA infusion and about 19 h after infusion. A short survey including demographic data and past medical history has been completed. None of patients had clinically important arrhythmias before ZA infusion. We divided arrhythmias into two groups as supraventricular and ventricular. We evaluated arrhythmias in pre-infusion, during infusion, and post-infusion periods. ZA was administered 4 mg intravenously (IV) in 15 min. Thirty-three of patients (63.5 %) were male and 19 (36.5 %) patients were female. Mean age of the patients was 53.9 ± 11.8 years. Most frequent cancers were breast (25 %) and lung cancer (15.3 %). Twelve (23 %) patients had history of mediastinal radiotherapy. In basal records, we detected that twenty-four (46 %) of patients had supraventricular premature complexes (SVPC) or ventricular premature complexes (VPC). Fifteen (28.8 %) of patients had SVPC and fourteen (26.9 %) had VPC during infusion period. After infusion period, 48 (92.3 %) of patients had SVPC and 41 (78.8 %) had VPC. Only 3 patients had no arrhythmia after infusion. Three patients had sinus arrhythmia and two had Mobitz type 2 atrioventricular blocks after infusion. One patient, who had no history of comorbidities and had SVPC in the basal records, developed atrial fibrillation that was refractory to medical cardioversion after 10 days of seventh dose of ZA infusion. In this study, we found that both SVPC and VPC increased in cancer patients treated with ZA. Furthermore, ZA may induce clinically important arrhythmias.

The predictive value of QRS duration in response to levosimendan therapy in patients with decompensated heart failure.

PURPOSE: We aimed to investigate the role of QRS duration on the surface electrocardiogram (ECG) in predicting response to levosimendan therapy in patients with acute systolic heart failure. METHODS: Patients with an ejection fraction (EF) lower than 35% who required intravenous inotropic support despite optimal heart failure therapy were included in this study. Patients were divided into two groups according to QRS durations on ECG. Group 1 (n=16) included patients with a QRS duration equal to or shorter than 120 ms and group 2 (n=14) included patients with a QRS duration longer than 120 ms. New York Heart Association (NYHA) functional class, plasma BNP levels and echocardiographic measurements were compared within and between groups before and after the infusion. RESULTS: In both groups statistically significant improvement was observed in NYHA class, plasma BNP levels and left ventricular end-systolic diameter after the levosimendan infusion compared to baseline (P < 0.025). In addition, in group 1 patients, left atrial diameter, left atrial volume, left ventricular end-diastolic diameter, left ventricular end-diastolic volume, left ventricular end-systolic volume (LVESV), left ventricular EF, mitral E velocity, mitral annular Aa and Sa parameters improved after the infusion compared to the baseline values (P < 0.025). Comparison of both groups revealed improvement of NYHA class, an increase of left ventricular EF and a signficant decrease of LVESV after levosimendan in group 1 (P < 0.05). CONCLUSION: QRS duration on ECG may be used as a practical bedside indicator in estimating short-term response to levosimendan therapy.

Valvular heart disease: plasma B-type natriuretic peptide levels in patients with pure rheumatic mitral stenosis.

OBJECTIVE: Our study is designed to evaluate the plasma BNP levels in patients with pure MS and its possible correlation with clinical and echocardiographic parameters of the disease. METHODS AND RESULTS: The study included 29 patients (27 women, 2 men, mean age 43.4 +/- 11.8 y) with pure mitral valve stenosis in sinus rhythm and 24 age- and gender-matched healthy voluteers (17 women, 7 men, mean age 42 +/- 13 y). Plasma BNP levels were significantly higher in the mitral stenosis group compared to controls (91.1 +/- 69.6 pg/ml vs. 14.4 +/- 9.2 pg/ml, P < 0.0001). In univariate analysis, plasma BNP levels correlated positively with left ventricular end-systolic diameter (r = 0.439, P = 0.041), left atrial diameter (r = 0.772, P < 0.001), peak diastolic transmitral gradient (r = 0.621, P = 0.003), mean diastolic transmitral gradient (r = 0.751, P < 0.001), peak systolic pulmonary artery pressure (r = 0.467, P = 0.044), functional capacity (r = 0.819, P < 0.001) and negatively with left ventricular ejection fraction (r = -0.482, P = 0.020) and planimetric mitral valve area (r = -0.494, P = 0.006). No significant correlation existed between age, end-diastolic diameter and right ventricular diameter (r = 0.185, P = 0.337; r = 0.227, P = 0.309; r = 0.319, P = 0.092; respectively). A receiver operating characteristic (ROC) curve identified a BNP value of 32 pg/ml as the best cut-off for the identification of patients with mitral stenosis with a positive predictive value of 100% and a negative predictive value of 75%. CONCLUSIONS: In this study we found elevated plasma BNP levels in patients with pure MS in sinus rhythm. Plasma BNP levels correlated with disease severity and this can have potential clinical implications, for example in patients undergoing percutaneous balloon mitral valvuloplasty or in patients with poor echocardiographic windows.

Zolmitriptan-induced acute myocardial infarction.

Triptans are an established treatment for acute migraine attacks. By activating 5HT1B/1D receptors they lead to vasoconstriction of the cerebral blood vessels which are dilated during migraine attacks. Moreover, they reduce secretion of vasoactive peptides and conduction of pain stimuli over the cerebral cortex. In up to 7% of cases of treatment with triptans, thoracic pain occurs, although this is mostly transient, mild and without lasting ischemia. We present the case of a 45 year-old woman with a history of migraine with visual aura since the age of 20. She had no history of diabetes mellitus, hypertension, smoking or any other risk factors for cardiovascular events before she was admitted to our emergency room with typical chest pain. An electrocardiogram revealed anterior myocardial infarction following her monthly dose of oral zolmitriptan. Catherization revealed a normal coronary arterial system. The laboratory indices for cardiac risk were within normal ranges. The patient was advised to avoid triptans permanently on being discharged.

Value of IGF-I levels in the evaluation of response to treatment with levosimendan in patients with severe heart failure.

OBJECTIVE: Levosimendan treatment has inotropic, anti-stunning, and cardioprotective effects in the setting of acute decompensated heart failure (HF). Among studies conducted on the treatment of heart failure, those based on the growth hormone axis are of particular interest. The aim of this study was to determine the value of baseline insulin-like growth factor 1 (IGF-I) measurements in predicting response to levosimendan treatment. METHODS: The study population included patients on standard heart failure treatment who presented with functional capacity NYHA class 3-4 and left ventricular (LV) ejection fraction less than 35% were enrolled in this prospective, cohort study. Pre- and post-treatment symptoms of patients (72 hours after the completion of levosimendan infusion) and echocardiographic parameters were evaluated and blood samples were collected. Mann-Whitney U, Pearson Chi-square and Wilcoxon Sign Rank tests were used for statistical analysis. Correlations were determined using Spearman correlation analysis. RESULTS: Thirty patients were enrolled in this study, 83.3% of whom were male and 16.7% were female, with a mean age of 62.6 ±10.1 years. Mean baseline IGF-I level was 106.9±47.0 µg/L. Statistically significant improvements were observed in NYHA class, mean brain natriuretic peptide (BNP) levels, LV ejection fraction and LV end-systolic volume values following treatment with levosimendan (respective pre-treatment and post-treatment values: 3.5±0.5 vs. 2.5±0.7, p<0.001; 1209.8±398.6 pg/ml vs. 704.1±344.6 pg/ml, p<0.001, and 25.7±6.6% vs. 29.0±6.8%, p=0.021, and 164.1±45.7 ml vs. 152.8±50.6 ml, p=0.012). Fourteen patients (46.7%) had low IGF-I levels, taking into consideration variations due to age and gender. Patients with normal baseline IGF-I values showed more significant decreases in BNP levels in response to treatment compared to those with low baseline IGF-I levels (650.5±367.2 pg/ml vs. 340.1±269.0 pg/ml, p=0.014). CONCLUSION: Baseline IGF-I levels may be used to predict response to levosimendan treatment in patients hospitalized for decompensated HF.

Coronary artery-left ventricular microfistulae associated with apical hypertrophic cardiomyopathy.

A 58 year-old Caucasian man was admitted to the coronary care unit with angina pectoris. There were deep inverted T waves and ST segment depression at anterior precordial derivations. Coronary angiography revealed widespread coronary artery to left ventricular microfistulae arising from distal portions of both left and right coronary systems. Left ventriculography and transthoracic echocardiography revealed typical features of apical hypertrophic cardiomyopathy. Angina pectoris was alleviated by beta-blocker therapy. Both multiple coronary artery to left ventricular microfistulae and apical hypertrophic cardiomyopathy are rare conditions and little is known about pathophysiological and clinical aspects of this combination. Accumulating evidence will provide us this information so that the management of the patients will be enhanced.

Assessment of planimetric mitral valve area using 16-row multidetector computed tomography in patients with rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Transthoracic two-dimensional echocardiography (TTE) is currently the 'gold standard' for the evaluation of rheumatic mitral valve disease. Multidetector computed tomography (MDCT) is a promising technique for the evaluation of heart valves. The study aim was to evaluate the planimetry of the mitral valve area (MVA) with 16-row MDCT in comparison with TTE, in patients with rheumatic mitral stenosis. METHODS: Twenty-six patients (18 females, eight males; mean age 41.7 +/- 8.7 years) with rheumatic mitral valve disease, who had been referred for 16-row MDCT for various indications, such as evaluation of the coronary arteries, assessment of pulmonary vein anatomy before catheter ablation of paroxysmal atrial fibrillation, suspicion of aortic dissection or pulmonary embolism, were recruited. All patients were in sinus rhythm. The MDCT acquisition was performed using a 16-row scanner. Echocardiographic planimetry of MVA was performed in the standard parasternal short-axis view within one week. RESULTS: Planimetry of the MVA with MDCT did not differ from that with TTE (1.88 +/- 0.46 cm2 versus 1.83 +/- 0.50 cm2, p = 0.242), and there was an excellent correlation between two techniques (r = 0.923, p < 0.0001). Seven patients had calcific mitral valves (mean calcium score 216.8 +/- 783.8 Agatston units). In these patients, MVA measured by MDCT was 1.73 +/- 0.39 cm2 and by TTE planimetry was 1.72 +/- 0.54 cm2 (p = 0.866; r = 0.963, p = 0.0005). When using the pressure half-time (PHT) method, the MVA was obtained in 24 of the 26 patients. MVA by PHT did not differ from the MVA calculated by TTE planimetry, nor from that obtained with MDCT planimetry (1.79 +/- 0.46 cm2 versus 1.81 +/- 0.51 cm2, p = 0.427 and 1.79 +/- 0.46 cm2 versus 1.86 +/- 0.48 cm2, p = 0.101, respectively). The correlation coefficient for the MDCT-derived MVA and PHT-derived MVA was 0.8969 (p < 0.0001). Although not statistically significant, in nine patients with moderate to severe mitral stenosis (MVA < 1.5 cm2), the MDCT tended to overestimate MVA compared to echo planimetry (1.35 +/- 0.19 cm2 versus 1.28 +/- 0.21 cm2, p = 0.059). CONCLUSION: MDCT enabled accurate planimetry of the MVA in patients with rheumatic mitral stenosis, in comparison with TTE.

Left ventricular noncompaction associated with a sinoatrial node artery originating from the posterolateral branch of the right coronary artery.

Noncompaction of the ventricular myocardium (NVM) is a rare unclassified cardiomyopathy which is characterized by multiple prominent trabeculations and deep intertrabecular recesses. This cardiomyopathy can be isolated or in combination with other congenital cardiac disorders, including coronary artery abnormalities. A 56-year-old female patient presented to the cardiology department with complaints of exertional dyspnoea and chest pain. Transthoracic echocardiography revealed left ventricular dilatation with diffuse hypokinesis. Multiple prominent trabeculations with deep inter-trabecular recesses were observed at the left ventricular apex. Also, coronary angiography demonstrated a sinoatrial node artery originating from the posterolateral branch of the right coronary artery.

Long-Term Survival Following Cardiac Arrest Without Implantable Defibrillator Protection in a Hypertrophic Cardiomyopathy Patient.

Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young people. Implantable cardioverter defibrillator (ICD) is the optimal therapy in patients with HCM, both for primary or secondary prevention of sudden death. Left ventricular systolic function in HCM is usually normal. However, in few patients, HCM has been reported to progress to a state that is characterized by left ventricular dilation and systolic dysfunction, resembling dilated cardiomyopathy (DCM). Although arrhythmias are common in HCM, advanced or complete atrioventricular block (AV) is very rare. This case report describes a HCM patient who progressed to DCM with advanced AV block and survived 31 years following cardiac arrest without ICD protection.

A case of systemic lupus erythematosus presenting with hypereosinophilia and Loeffler endocarditis.

A 15-year-old boy who was admitted to the neurology department had multiple cerebral infarcts on cranial magnetic resonance imaging. A transthoracic echocardiogram revealed myocardial thickening and apical thrombus in the left ventricle suggesting Loeffler endocarditis. There was remarkable hypereosinophilia on the haemogram. An investigation for the aetiology of hypereosinophilia led to the diagnosis of systemic lupus erythematosus and associated antiphospholipid syndrome. This case represents a very rare case of systemic lupus erythematosus in which the initial presentation was hypereosinophilia related Loeffler endocarditis.

A rare complication of radiofrequency catheter ablation of left atrial tachycardia: atrial septal dissection and left atrial hematoma formation.

A 52-year-old man with left atrial tachycardia underwent radiofrequency catheter ablation. A steerable 4-mm-tip ablation catheter was advanced into the left atrium through a patent foramen ovale without transseptal puncture. However, the tip of the catheter was stuck in a structure. A pull-back maneuver rendered the catheter free and the procedure was cancelled. Transthoracic and transesophageal echocardiograms obtained immediately after the procedure showed intimal layer dissection in the interatrial septum and intramural hematoma formation throughout the anterior left atrial wall. The patient was in stable condition. Therefore, he was followed-up conservatively with serial echocardiographic examinations. The dissected intimal layer disappeared in 10 days and the hematoma underwent near-complete resolution in three months. This case highlights a rare complication of catheter ablation procedure that all interventionists should be familiar with.

Single coronary artery arising from the right sinus of Valsalva.

Single coronary artery (SCA) is a rare congenital anomaly in which the entire coronary system arises from a solitary ostium. A 65-year-old male with a history of diabetes mellitus, hypertension, and hyperlipidemia was admitted with exertional angina pectoris of new onset. His physical examination, hemogram, thyroid function tests, chest X-ray, electrocardiogram, and transthoracic echocardiogram were normal. In treadmill exercise test, the patient could not reach submaximal heart rate due to fatigue. Coronary angiography revealed an SCA arising from the right sinus of Valsalva (type R-IIA). The left coronary artery (LCA) coursed anteriorly in front of the right ventricular outflow tract and gave off branches for the left anterior descending and left circumflex (LCx) arteries. A mild diffuse nonobstructive atherosclerotic lesion was also detected in the LCx. The entire SCA and the anterior course of the LCA in relation to the great vessels were further displayed by 16-row multislice computed tomography. The atherosclerotic lesion was not eligible for percutaneous intervention and the patient was scheduled for medical therapy with recommendation of risk factor modification.

Assessment of global left ventricular systolic function with multidetector CT and 2D echocardiography: a comparison between reconstructions of 1-mm and 2-mm slice thickness at multidetector CT.

PURPOSE: To compare multidetector computed tomography (MDCT) and two-dimensional transthoracic echocardiography (2DE) for left ventricular ejection fraction (EF); and to make comparison between reconstructions of 1-mm and 2-mm slice thickness at MDCT in left ventricular analysis by using a semiautomated segmentation algorithm. MATERIALS AND METHODS: In 43 patients global left ventricular systolic function was assessed by using both MDCT and 2DE. Functional MDCT data sets were reconstructed in 20 cardiac phases (0-95%) with both 1-mm and 2-mm slice thickness.With semi-automatic left ventricle segmentation, end-diastolic volume (EDV), endsystolic volume (ESV) and EF were calculated seperately for both 1-mm and 2-mm reconstructions. RESULTS: On MDCT with 1-mm slice thickness, mean EF was 66.8 +/- 5.6 %, mean EDV was 133.7 +/- 38.9 mL, and mean ESV was 45.1 +/- 17.9 mL, these values for 2-mm slice thickness were 66.2 +/- 5.6 %, 133.5 +/- 39.6 mL, and 45.9 +/- 18.3 mL, respectively. On 2DE, mean EF was 66.7 +/- 5.7 %, mean EDV was 98.7 +/- 42.1 mL, and mean ESV was 33.6 +/- 18.7 mL. There was no difference between EF values calculated with 1-mm and 2-mm reconstructions and 2DE (P = 0.83 and P = 0.3705, respectively). However, EDV and ESV values calculated by MDCT were significantly higher than those obtained by 2DE (P < 0.0001). CONCLUSION: There was a good correlation between MDCT and 2DE in the evaluation of left ventricular EF. At MDCT left ventricular ESV was statistically smaller, EF was statistically greater by using 1-mm rather than 2-mm slice thickness. However, these differences are not clinically relevant.