An Incessant Tachycardia with Alternating QRS Complexes: What Is the Mechanism?

We present a patient with ischemic cardiomyopathy who had ventricular tachycardia (VT) with QRS morphology alternans. The electrophysiological findings, in this case, supported the occurrence of antegrade activation of the proximal His-Purkinje system during VT, with the ultimate electrocardiogram morphology dependent on fusion from intramyocardial and His-Purkinje activations.

An Unusual Electrogram Sequence with a Questionable Potential on the His-bundle Catheter During Sinus Rhythm: What Is the Mechanism?

The presence of 2 ventricular signals caused by structures near the His bundle region is rare. Some associative and dissociative maneuvers for dissociating a certain electrical signal from others of known origin are used to ascertain the source of an unknown potential.

Accessory Pathway in Ebstein's Anomaly: Absence of Evidence Is Not Evidence of Absence.

Electrocardiography has certainly great merit and is almost abnormal in most patients with Ebstein's anomaly. Incomplete or complete right bundle brunch block (RBBB) is seen in almost half of these patients. The absence of the expected RBBB during sinus rhythm in a patient with Ebstein's anomaly is a useful clue of pre-excitation in these patients.

A Wide QRS Tachycardia with Three Distinct Left Bundle Branch Block Morphologies in a Patient with Sinus Rhythm with Left Bundle Branch Block: What Is the Mechanism?

The differential diagnosis for a wide complex tachycardia includes all causes of supraventricular tachycardia (SVT) with bundle branch block or all causes of SVT with antegrade pre-excitation by bystander involvement of any accessory pathways, myocardial or bundle brunch ventricular tachycardia, and antidromic (atriofascicular or nodofascicular/nodoventricular) and other pre-excited reciprocating tachycardias. We present a case of wide complex QRS tachycardia with a left bundle branch block QRS morphology.

Telltale termination of an A-on-V tachycardia with two blocked atrial activations: What is the mechanism?

The termination of tachycardia may provide important clues toward the mechanism of the tachycardia and that close vigilance may clinch the diagnosis before proceeding to other pacing maneuvers.

The transition of the tachycardia from narrow to wide by a spontaneous atrial premature beat: What is the mechanism?

The transition of the tachycardia from narrow to wide by a spontaneous atrial premature contraction causing a long-short sequence and right bundle branch block.

A dual nodal response to the parahisian pacing and induction of the retrograde right bundle branch block maneuvers.

We presented intracardiac electrograms during the parahisian pacing, which represent three types of retrograde conduction and focus on the mechanism of types of retrograde conduction on wide QRS complexes and conclude that the two types of QRS of the retrograde conduction resulted from the presence or absence of retrograde block at the right bundle branch.

Relation Between Globulin, Fibrinogen, and Albumin With the Presence and Severity of Coronary Artery Disease.

The albumin to globulin ratio (AGR) is used as a prognostic marker in acute ischemic cardiovascular events. We investigated whether serum AGR, fibrinogen, and fibrinogen to albumin ratio (FAR) are related to the presence and severity of coronary artery disease (CAD). Patients who underwent coronary angiography procedures were analyzed retrospectively. The severity of CAD was assessed by the Gensini score. The study population (3031 patients; 1071 females and 1960 males) was divided into 3 tertiles based on AGR values. Gensini score, lipid levels, diabetes mellitus (DM), hypertension (HT), age, and fibrinogen level were higher in the low AGR group. Pearson correlation analysis showed that AGR (r = -0.068, P < .001) was negatively and fibrinogen (r = 0.187, P < .001) was positively correlated with the Gensini score. Male gender, HT, smoking, DM, age, high triglyceride (TG) level, low-density lipoprotein cholesterol (LDL-C) >160 mg/dL, estimated glomerular filtration rate (eGFR) <60 mL/min, and fibrinogen level >3.5 g/L were independent predictors of CAD. Male gender, age, eGFR, DM, LDL-C, TG, and FAR had an independent positive relation to the Gensini score. In conclusion, similar to traditional risk factors, plasma fibrinogen and albumin levels showed a close relation with the presence and severity of CAD.

Successful Percutaneous Coronary Intervention for Chronic Total Occlusion of Left Anterior Descending Coronary Artery in a Patient with Dextrocardia.

Dextrocardia is a rare cardiac anomaly in which the heart is located in the right chest along with the cardiac long axis directing to the right and inferiorly. Although, it is a rare clinical phenomenon, coronary artery disease with dextrocardia is presumed to be of similar frequency as in the general population. Percutaneous coronary intervention has some technical difficulties in these patients. We hereby report a male patient with dextrocardia who was previously treated with coronary artery bypass graft surgery.

Right ventricular outflow tract function in chronic heart failure.

BACKGROUND: Heart failure (HF) is a common, progressive, complex clinical syndrome and a subset of HF patients has symptoms out of proportion to the resting hemodynamics and left ventricular ejection fraction (LVEF). Right ventricular (RV) function is a powerful prognostic factor in HF, but assessing it is a challenge because of the right ventricle's complex geometry. OBJECTIVE: The aim of this study was to investigate the clinical application value of RV outflow tract (RVOT) function measured by transthoracic echocardiography in HF patients. METHOD: We prospectively investigated 36 chronic HF patients with dilated heart and LV systolic dysfunction and 21 healthy control subjects (normal ventricular function and ECG, and no cardiac risk factors). In addition to clinical and conventional echocardiographic parameters, RVOT size and fractional shortening (RVOT-FS) parameters were analyzed. RESULTS: The RVOT-FS was less in HF patients than healthy controls (18.8±15.7 vs 55.8±6.7, p<0.001) and correlated positively with TAPSE (r=0.814, p<0.001) and inversely with SPAP (r=-0.728, p<0.001) and functional capacity (r=-0.842, p<0.001). There was a statistically significant difference in RVOT-FS among the HF subgroups with regard to NYHA functional capacity (p<0.001), although there was no statistically significant difference with regard to LVEF. CONCLUSION: Although the apparent discordance between LVEF and the degree of functional impairment in HF is not well understood, it may be explained in part by alterations in RV function. We found that the RVOT-FS was a noninvasive and easily applicable measure of RV function and might be used for a comprehensive evaluation and follow-up of HF patients with a combined assessment of RV by other RV parameters.

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.

Hepatitis C infection is associated with increased coronary artery atherosclerosis defined by modified Reardon severity score system.

BACKGROUND: The link between arteriosclerotic disease in the carotid or coronary artery and chronic hepatitis C virus (HCV) infection has been shown in some studies although other studies have produced contrary results. However, the effect of chronic HCV infection on the extension or severity of coronary artery disease (CAD) has not been determined so the aim of the present study was to determine the effect of HCV infection on the severity of CAD. METHODS AND RESULTS: The study group comprised 139 HCV seropositive and 225 HCV seronegative patients with angiographically documented CAD. A modified scoring system of Reardon et al was used. There were no significant differences between groups in terms of sex, age, hypertension, diabetes mellitus, smoking or family history. Levels of C-reactive protein and fibrinogen were significantly higher in the HCV seropositive group (p<0.001) and the Reardon severity score was higher (8.75+/-1.69 vs 6.01+/-1.80, p<0.001). After adjustment, HCV seropositivity still represented an independent predictor for severity of coronary atherosclerosis demonstrated by higher Reardon severity score with an odds ratio of 2.018 (95% confidence interval 1.575-2.579, p<0.001). CONCLUSION: HCV infection is an independent predictor for increased coronary atherosclerosis, as demonstrated by higher Reardon severity score.

Circulating CD4+CD25+ T cells in rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Autoimmunity plays an essential role in the pathogenesis of rheumatic heart disease. Although the ongoing rheumatic process has been demonstrated with high levels of inflammatory markers, the cellular mechanism(s) of autoimmunity have not yet been investigated. The study aim was to examine levels of circulating CD4+CD25+ T cells in patients with rheumatic mitral stenosis, and to evaluate the relationship between regulatory CD4+CD25+ T-cell count and clinical and echocardiographic measures. METHODS: A total of 42 patients with mitral stenosis was enrolled into the study, and 27 normal age- and gender-matched healthy subjects served as controls. All patients and controls underwent clinical, electrocardiographic, echocardiographic and laboratory evaluation. T-cell levels were determined with flow cytometry using monoclonal fluorescein isothiocyanate-labeled anti-CD4 and phycoerythrin-labeled anti-CD25 antibodies. RESULTS: The circulating CD4+CD25+ T-cell count was significantly lower in patients with mitral stenosis than in controls (231 +/- 120 versus 372 +/- 180 per mm3; p = 0.001). The percentage ratio of CD4+CD25+ T cells to total leukocytes and lymphocytes was significantly lower in patients with mitral stenosis than in controls (2.9 +/- 1.5 versus 5.2 +/- 2.1; p < 0.001, and 11.2 +/- 5.6 versus 14.8 +/- 5.6; p = 0.011, respectively). In addition, a significant negative correlation was identified between the erythrocyte sedimentation rate and circulating CD4+CD25+ T-cell count (Spearman rho = -0.414; p = 0.006). No correlation was found between CD4+CD25+ T-cell count and clinical and echocardiographic parameters in patients with mitral stenosis. CONCLUSION: A decrease in CD4+CD25+ T cell numbers in mitral stenosis patients might suggest a role for cellular autoimmunity in a smoldering rheumatic process.

A rare cause of sudden vision loss in a young male: papillary fibroelastoma of the aortic valve.

Cardiac papillary fibroelastoma (CPF) is a rare cardiac neoplasm predominantly affecting the cardiac valves. Although it is most commonly an incidental finding, it can result in life-threatening complications, such as coronary and cerebral embolism, acute valvular dysfunction, and sudden death. In this report, we describe a case of a patient with aortic valve papillary fibroelastoma, which presented with sudden vision loss due to branch retinal artery occlusion. To the best of our knowledge, this is the third case of CPF-related retinal artery embolism in English literature.

QT dispersion significantly increases after implantable cardioverter-defibrillator shocks.

OBJECTIVE: To determine whether QT dispersion (QTd), a noninvasive electrocardiographic parameter of ventricular tachyarrhythmia risk assessment, is changed by implantable cardioverter-defibrillator (ICD) shocks delivered during implantation process, to analyze the duration of these changes, and to further evaluate the effect of amiodarone on these parameters. METHODS: Twenty-six consecutive patients who are scheduled to undergo ICD implantation for aborted sudden cardiac death or documented symptomatic sustained ventricular tachycardia were enrolled into the study. A simultaneous 12-lead electrocardiogram (ECG) was recorded after the ICD implantation just before starting the testing shock when the patients were under general anesthesia (baseline record) and at 1st, 5th, 10th, 15th, 20th, 25th, and 30th minutes after the successful shocks. RR interval, QT interval, corrected QT interval (QTc), QTd, and corrected QTd (QTcd) were all measured and calculated on ECG. RESULTS: At 1st minute after the successful shock, an abrupt increase (from 67.0 +/- 13.8 ms to 94.8+/-21 ms, P < 0.0001) was observed in QTcd, which was followed by a gradual return to the preshock values at 20th minute. Analysis of patients with and without long-term oral amiodarone treatment showed that in amiodarone-pretreated patients QTcd returned to the baseline value earlier than in patients without amiodarone treatment (15 minutes vs 20 minutes, respectively). CONCLUSIONS: ICD shocks cause an increase in QTcd lasting for up to 20th minute, which may predominate in some important clinical problems like electrical storm. Amiodarone, with the desirable effect on QTcd, may reduce the proarrhythmic effects of ICD shocks.

Comparison of the electrocardiographic features of complete left bundle branch block in patients with ischemic and nonischemic left ventricular dysfunction.

BACKGROUND: Differentiating ischemic (ILVD) from nonischemic left ventricular dysfunction (NILVD) is important prognostically and therapeutically but might be difficult clinically. The differentiating role of electrocardiographic (ECG) features in the presence of left bundle-branch block (LBBB) is debatable on differentiating ILVD from NILVD. OBJECTIVE: The present study assessed whether there is the role of certain ECG features in differentiating ILVD from NILVD in the presence of the complete LBBB. METHODS AND RESULTS: Patients who had LBBB were divided into two groups based on the presence and type of left ventricular dysfunction; (1) ILVD group (49 patients; 20 female; age: 65 +/- 11 years) and (2) NILVD group (49 patients; 22 female; age: 59 +/- 12 years), and numerous ECG features were compared. Most of these ECG features did not show any difference between the groups except for following ECG findings; the voltage of R wave in V6 were statistically higher in NILVD group compared ILVD group (p: 0.03); the depression of the ST-J point by more than 0.2 mV in V6 were also frequently observed in NILVD group compared ILVD group (5/ 10% vs 19/ 39% , p: 0.001); and the notching in the ascending or descending limb of the S wave in V1-4 leads were more in ILVD group (18/ 36% vs 8/ 16% p: 0.03; 9/ 16% vs 2/ 4%, p: 0.03, respectively). CONCLUSION: In the current study, although some ECG findings were found to be useful, ECG features in the presence of complete LBBB had poor value in differentiating ILVD from NILVD.