The prevalence and the prognostic value of microvolt T-wave alternans in patients with hypertrophic cardiomyopathy.

BACKGROUND: Nonsustained ventricular tachycardia (nVT) may have ominous implications for patients with hypertrophic cardiomyopathy (HCM). The microvolt T-wave alternans (TWA) has been proposed as a noninvasive tool-identifying patients at risk of sudden cardiac death and ventricular tachycardia/fibrillation (VT/VF). The aim of the study was to determine the significance of TWA in predicting nVT episodes and compare how other electrocardiographic parameters can predict the occurrence of nVT. METHODS: The study group consisted of 88 patients with HCM. TWA was assessed during exercise test using the CH2000 system. All patients underwent Holter monitoring (HM) within 2-4 weeks before TWA test (preexercise HM1) and immediately after (postexercise HM2). During HM, we analyzed: arrhythmias, QT intervals, the presence of late ventricular potentials (LP), heart rate variability, heart rate turbulence. RESULTS: Depending on TWA results, the patients were divided into two groups: TWA+; 46 patients (52.3%) with positive/indeterminate results, and TWA-; 42 patients (47.7%) with negative results. The nVT episodes were more frequent among TWA(+) both in HM1 and HM2. The presence of TWA increases the risk of postexercise nVT over twenty times (OR = 21.03). Moreover, in HM1, QTc and LP, and in HM2, again QTc and N-terminal precursor of brain natriuretic peptide proved to be significant predictors of nVT. The addition of TWA to the models did not improve the arrhythmia risk assessment. CONCLUSIONS: Repolarization abnormality plays an important role in generating nVT in patients with HCM, but TWA does not specifically predict the risk of arrhythmic end point.

Repeatability of sleep apnea detection in 48-hour holter ECG monitoring.

BACKGROUND: There is a significant relationship between obstructive sleep apnea (OSA) and cardiovascular diseases. Reliability of new methods evaluating apnea in Holter ECG monitoring is still the matter of investigators' studies. METHODS: In 48-hour Holter ECG monitoring recordings of 63 patients, we assessed repeatability, comparing the results from both sleep periods. RESULTS: We found good repeatability in evaluation of apnea-hypopnea index value. There was moderate agreement in three categories, that is, normal or bordeline or apneic assignment. Assignment to "healthy" (normal and borderline) or apneic subgroup during consecutive sleep periods showed high repeatability. CONCLUSIONS: Holter ECG monitoring is a repetitive method of preliminary diagnosis in patients evaluated for sleep apnea syndrome.

M-mode speckle tracking--a novel echocardiographic approach to assess left ventricular torsional deformation.

BACKGROUND: Speckle tracking echocardiography (STE) requires special image processing for complex assessment of left ventricular (LV) function, including strain and rotation. AIM: To evaluate a novel M-mode STE technique as a readily applicable approach, providing potential insights into LV deformation. METHODS: Fifty one patients (mean age 52 +/- 14 years, 24 women) with normal or impaired LV function (mean LVEF 51 +/- 16%, range between 14% and 66%) were studied. Left ventricular rotation at mitral valve and apical level was measured using dedicated conventional STE software. Grey-scale short axis digital loops at mitral valve level were also used to obtain M-mode STE images, presenting the movement of LV wall speckles along the cursor, with the LV cavity left out. Then, the distance of peak systolic shift (PSS) was measured for one selected speckle. RESULTS: Mean rotation at mitral valve level was 7.4 +/- 3.1 degrees , apical rotation was 7.6 +/- 6.4 degrees and LV torsion was 14.9 +/- 7.1 degrees . Measurement of PSS with a novel M-mode STE approach was feasible in all patients, producing a mean value of 7 +/- 2 mm. Subsequently, two subsets with PSS of less than 7 mm and PSS equal to or above 7 mm showed a significant difference between mean LV torsion of 10.7 degrees and 17.0 degrees , respectively (p = 0.002). In the ROC analysis, PSS cut-off value of less than or equal to 7 mm yielded a sensitivity of 92% and a specificity of 61% to predict LV torsion < 10.7 degrees (p < 0.0001). CONCLUSIONS: M-mode STE appears to be a feasible approach to detect movement of speckles and to measure PSS within the LV inferior and septal wall in short axis view images. PSS cut-off value of less than 7 mm indicates significantly lower LV torsion. Further studies are required to assess the potential role of M-mode STE in cardiac imaging.

Myocardial infarction in young people.

An estimated 6 to 10% of myocardial infarctions occur in patients under the age of 45. Usually this applies to men, but an increasing prevalence is being observed among women. Atherosclerosis, often one vessel disease, is the main cause. The presence of classic risk factors affects the dynamics of coronary artery disease: the strongest risk factor is smoking, regardless of gender. Environmental influence is also possible. No atherosclerosis is found in 20% of young patients. In such cases, the most frequent mechanisms of ischemia are: coronary artery embolism (5%), thrombosis (5%), anomalies (4%) and inflammation or spasm of the vessel. Age is an independent prognostic factor. Thus the clinical outcome after myocardial infarction is better in younger than in older patients.

Early prediction of ventricular recovery in Takotsubo syndrome using stress and contrast echocardiography.

BACKGROUND: Takotsubo syndrome is a primary, stress-provoked acquired cardiomyopathy mimicking acute myocardial infarction. Because of the less severe prognosis of takotsubo patients, a reliable method of predicting complete functional recovery has great practical value. CASE REPORT: A case of takotsubo syndrome is reported in a 59-year-old Caucasian woman in whom early echocardiographic imaging demonstrated normal myocardial perfusion and contractile reserve predictive of complete functional recovery. The patient was admitted with symptoms of acute coronary syndrome triggered by severe stress. Coronary angiography revealed no stenosis, whereas echocardiography revealed wall motion abnormalities of the left ventricular apex with an ejection fraction of 30%. Using low-dose dobutamine stress echocardiography and myocardial contrast echocardiography, the preliminary diagnosis of takotsubo cardiomyopathy was confirmed and a good prognosis regarding the recovery of wall motion abnormalities was predicted. After 30 days, echocardiography revealed fully restored ventricular function and a 270-day follow-up was uneventful. CONCLUSIONS: Microcirculation assessment using myocardial contrast echocardiography as well as early contractile reserve in a low-dose dobutamine echocardiographic test might be useful in the prediction of functional recovery in suspected takotsubo syndrome.

The relationship between left ventricular late-systolic rotation and twist, and classic parameters of ventricular function and geometry.

BACKGROUND: Using speckle tracking echocardiography we investigated left ventricular (LV) twist and rotation (ROT) at the papillary muscle (PM) level and their correlation with standard echocardiographic and demographic parameters. AIM: To assess whether the fulcrum of LV short axis ROT is shifted in myocardial disease. METHODS: The study group consisted of 33 patients (54+/-13 years old, 18 women). Left ventricular systolic function was normal in 6, and various degrees of wall motion abnormalities were present in the others [LV ejection fraction (LVEF) 49+/-15, wall motion score index (WMSI) 1.43+/-0.38]. Short axis images at basal, PM and apical level were analysed offline. The direction of ROT was determined from the apical aspect and expressed in degrees: clockwise (CW) in negative values, counter CW in positive. Twist is the arithmetic difference between apical and basal ROT. RESULTS: Left ventricular twist was in the range of 0.4-27.5 (14+/-7) degrees and correlated with LV systolic diameter (LVS), r=-0.46, 95% CI from -0.69 to -0.13, p <0.01; LV diastolic diameter (LVD), r=-0.40, 95% CI from -0.65 to -0.06, p=0.02; and systolic motion score index of 6 mid segments (6S-MSI), calculated as WMSI at PM level, r=-0.37, 95% CI from -0.63 to -0.03, p <0.04. Linear regression resulted in a model including interventricular septum systolic thickness (IVSS) and 6S-MSI, which predicted twist correctly in 21% of cases. Twist was independent of LVEF and overall WMSI. The PM ROT value correlated with: apical ROT, r=0.36, 95% CI 0.02-0.63, p <0,04; posterior wall systolic thickness (PWS), r=0.39, 95% CI 0.05-0.64, p <0.03. We distinguished Group A, n=14, with CW direction of PM ROT - negative values, range from -5.2 to -0.9; Group B, n=19, with counter CW, range 0.4-4.9. Apical ROT was 5 vs. 10 degrees, p <0.03; PWS 14 vs. 15 mm, p <0.03; diastolic posterior wall thickness 10 vs. 12 mm, p <0.04, respectively. In univariate logistic regression, we identified independent factors related to counter CW PM ROT: apical ROT (OR=1.15, 95% CI 1.00-1.33, p <0.05) and PWS (OR=1.71, 95% CI 1.03-2.84, p <0.04). Multiple logistic regression resulted in a model predicting counterCW rotation at PM (p <0.01) including: apical ROT (OR=1.18, 95% CI 1.00-1.38, p <0.05) and PWS (OR=1.77, 95% CI 1.02-3.08, p <0.05). ROC curves identified cut-off values of apical ROT >11.3 deg and PWS >13 mm. We found counterCW PM ROT in all patients with both conditions, 59% of patients with one, 22% with none. CONCLUSIONS: Left ventricular twist is related to mid segments function and IVSS, while PM ROT value and its direction (associated with 'zero ROT level') is related to PWS and apical ROT, rather than to LVEF or WMSI. Thus twist and rotation may reflect novel aspects of LV function.

Impact of the time to reperfusion on early outcomes in patients with acute myocardial infarction undergoing primary angioplasty.

BACKGROUND: The ACC/AHA guidelines for management of patients with ST-elevation myocardial infarction (STEMI) have recommended primary PCI (pPCI) as the preferred reperfusion therapy, when it can be performed in a timely fashion, within 90-110 min from the first contact with medical personnel. The impact of treatment delays on outcomes in patients undergoing pPCI has been controversial. AIM: To evaluate the impact of time delays on in-hospital mortality and on the frequency of cardiac events during 30 days after STEMI. METHODS: 1723 patients were stratified on the basis of their time delays: from symptom onset until balloon inflation. The patients were divided into 4 groups: group 1 (311 patients) - time from symptom onset <90 min; group 2 (731 patients) - time delays of 90-180 min; group 3 (535 patients) - time delays of 180-360 min, and group 4 (146 patients) - time from symptom onset >360 min. RESULTS: The median time delay was 268.5+/-206 min, the median door to balloon time was 36.12+/-11.2 min. The patients with longer time delays (group 4) were older, more often were women, and had a higher frequency of diabetes, anterior MI and Killip class 4. During hospitalisation, 70 (4.1%) patients died. In-hospital mortality was significantly higher in group 4 (13.6%) than in other groups. Complications of STEMI such as cardiogenic shock considerably influenced mortality (45.6%). During a 30-day follow- -up, the patients with cardiogenic shock and the elderly had an increased risk of cardiac events. Also, time delays >360 min and failed pPTCA were independent adverse risk factors in multivariate regression analysis. CONCLUSION: Delays in time to pPCI have an impact on outcomes, especially in those treated >6 hours from the onset of symptoms.

[Acute mitral regurgitation caused by infarction-related papillary muscle rupture with successful surgical treatment: case report]. / Ostra niedomykalnosc mitralna spowodowana zawalowym peknieciem miesnia brodawkowatego skutecznie leczona operacyjnie - opis przypadku.

We present a case of severe complication of myocardial infarction -- acute mitral regurgitation caused by papillary muscle rupture. A 69-year-old man was admitted with chest pain lasting 1 hour and pulmonary oedema. ECG revealed ST-segment depression in leads II, III, aVF, V2-V6. Soon after admission the patient experienced respiratory disorders and consequently arrest. The patient was transferred in shock to the Department of Cardiothoracic Surgery, where he underwent successful artificial mitral valve implantation. One year later the patient is in good condition (NYHA class I) and the valve is fully functional.