Inappropriate shock and battery switching to "End of Life" in a patient with biventricular ICD during magnetic resonance imaging.

Presence of a cardiac pacemaker or implantable cardioverter defibrillator (ICD) is a relative contraindication to magnetic resonance imaging (MRI). Biventricular ICDs are often used in the treatment of advanced heart failure; however, reports on experience with biventricular ICDs are lacking in the literature. In this case report, we describe a pacemaker-dependent patient with a biventricular ICD on whom an MRI of the lumbar spine was performed without having realized the presence of the ICD.

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.

Paracardiac gossypiboma (textiloma) in 2 patients.

Gossypiboma, also called textiloma, results when a cotton matrix such as a gauze pad or surgical sponge is left in a body cavity after surgery. The diagnosis of gossypiboma can be challenging. In symptomatic patients, operative removal of the pad or sponge is recommended; however, the decision to operate might be less immediately clear in asymptomatic patients. We report the cases of 2 patients in whom we diagnosed paracardiac gossypiboma. In addition, we briefly review other cases and discuss the treatment of asymptomatic patients.

Prognostic value of neutrophil/lymphocyte ratio in patients with pulmonary embolism.

AIM: Preliminary evidence suggests that inflammation plays a role in the development and prognosis of pulmonary embolism (PE). We used the neutrophil/lymphocyte ratio (NLR) as a measure of systemic inflammation and investigated its association with PE. MATERIALS AND METHODS: A total of 266 patients who were diagnosed with PE and a control group of 124 age- and sex-matched healthy subjects were included in this study. We further classified the PE patients into 2 groups: those who survived and those who died in the first 30 days. Baseline NLR was measured by dividing neutrophil count to lymphocyte count and was compared between the groups. RESULTS: Median NLR was significantly higher among patients with PE compared to the healthy control group (3.9 (interquartile range (IQR): 5.0) vs. 1.9 (IQR: 0.6), P < 0.001). Of the 266 patients with PE, 16 (6%) died within 1 month. Median NLR was significantly higher among PE patients who died compared to those who survived, as well (3.7 (IQR: 4.3) vs. 9.0 (IQR: 7.9), P < 0.001). The optimal cut-off values, sensitivities, and specificities of NLR for predicting PE and in-hospital mortality of PE were >2.565 and >5.465, 70.3% and 75.0%, and 92.7% and 67.6%, respectively. Multiple logistic regression analysis showed that NLR values of >5.465 could define those patients with a mortal clinical course independently (odds ratio: 13.446, 95% confidence interval: 3.141-57.566, P < 0.001).

Association of prediabetes with diffuse coronary narrowing and small-vessel disease.

BACKGROUND: A significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics. OBJECTIVE: To evaluate whether there is an association between prediabetes and the coronary arterial size. METHODS: We prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as "normal," "prediabetic," and "diabetic" groups, and the coronary artery sizes and Gensini scores were analyzed. RESULTS: There were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p<0.001 in female group; Spearman's ρ: 0.252 p=0.016 in male group). CONCLUSION: We found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.

Pulmonary artery distensibility in chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary hypertension (PH) is an important complication in the natural history of chronic obstructive pulmonary disease (COPD) and is caused by the remodeling of pulmonary arteries impairing the distensibility and stiffness of the major pulmonary arteries. OBJECTIVES: To evaluate the pulmonary artery distensibility by transthoracic echocardiography in patients with COPD. METHOD: We prospectively investigated COPD male patients and compared with healthy controls. In addition to right ventricle (RV) conventional echocardiographic parameters, right pulmonary artery fractional shortening(RPA-FS) and new pulmonary artery stiffness (PAS) parameters were compared. RESULTS: Fifty-four COPD patients participated in the study and compared with a control group consisting of 24, all men, healthy, nonsmoking subjects. Six patients were excluded from study due to poor quality of echocardiographic recordings. The distensibility of PA evaluated by the RPA-FS parameter was found to be significantly lower in patients with COPD than it was in normal subjects (13.3 ± 8.1 vs. 27.6 ± 4.9,P :< 0.001) and correlated positively with tricuspid annular systolic excursion (TAPSE) (r = 0.566, P < 0.001) and pulmonary acceleration time (r = 0.607, P < 0.001) and correlated inversely with pulmonary artery systolic pressure (r = -0.587, P < 0.001), PAS(r = -0.479, P < 0.001) and functional capacity (r = -0.586, P < 0.001). Similar to this, PAS found to be impaired in COPD patients (29.5 ± 13.6 vs. 15.7 ± 4.1, P < 0.001) and correlated inversely RPA-FS (r = -0.479, P < 0.001). There were statistically significant difference for pulmonary artery distensibility (RPA-FS) and PAS parameters among the COPD subgroups with regard to NYHA functional capacity (P < 0.001). CONCLUSION: In this study, we found that PAS and distensibility were worsened in COPD patients and correlated with decreased functional capacity.

The role of the preoperative screening of sleep apnoea by Berlin Questionnaire and Epworth Sleepiness Scale for postoperative atrial fibrillation.

BACKGROUND: Undiagnosed obstructive sleep apnoea (OSA) is a risk factor for postoperative atrial fibrillation (POAF) as well as for heart disease in general. This necessitates screening during preoperative assessment to facilitate the implementation of strategies to minimise the postoperative risk. Overnight polysomnography is the "gold standard" for the diagnosis of OSA but may be impractical during preoperative assessment, and so questionnaires may be useful for screening OSA. The Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS) are two of the widely prescreening tools for persons who may suffer from sleep disorders. Thus, screening for and treating OSA as part of the routine preoperative evaluation of cardiac surgical patients may be a useful strategy for preventing POAF. OBJECTIVE: We investigated whether there is an association between POAF and sleep disorders evaluated by the BQ and ESS in this settings. METHODS: In 73 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and operational data were examined. During the clinical evaluation, all patients answered the ESS and BQ voluntarily upon admission. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalised. RESULTS: There were 33 patients with POAF and 40 patients without POAF as age- and gender-matched controls. The prevalence of high score in ESS was higher in POAF group compared to control group (52% vs 27%; p: 0.030). There was a higher prevalence of high risk for OSA in BQ in the POAF group (58% vs 34%; p: 0.044). CONCLUSION: Preoperative questionnaire-based diagnosis of OSA by the simple BQ and ESS may be useful in predicting POAF, and can be easily incorporated into routine screening of surgical patients undergoing CABG operation.

Intramyocardial hematoma with epicardial rupture following percutaneous coronary intervention.

Intramyocardial (or subepicardial) hematomas are uncommon conditions that occur mostly after myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass surgery, cardiac surgery, or chest trauma. Coronary perforation is a rare complication of PCI and the subset of patients developing an intramyocardial hematoma, usually considered a catastrophic event, is even rarer. We describe here the case of 63-year-old man in whom an intramyocardial hematoma with epicardial rupture occurred after PCI. The patient was treated conservatively with a successful outcome.

Exercise-related QT interval shortening with a peaked T wave in a boy with MEN 2 syndrome.

Multiple endocrine neoplasia 2 (MEN 2) is a hereditary syndrome associated with medullary thyroid carcinoma, pheochromocytoma (PCC), and hyperparathyroidism. PCCs in patients with MEN 2 are usually found in the adrenals after the manifestation of medullary thyroid cancer and are commonly bilateral and hormonally active. Unfortunately, a diagnosis of MEN 2 or PCC often is delayed until after the patient has developed an advanced MEN 2-related tumor. We present unusual electrocardiographic changes on exercise testing in MEN 2 syndrome. Transient peaked T waves and shortening QT during exercise stress testing may provide an early clue for undiagnosed PCC. .

Association of sleep apnea with coronary slow-flow phenomenon.

BACKGROUND: Both obstructive sleep apnea (OSA) and coronary slow-flow phenomenon (CSFP) are known to share similar etiopathogenic mechanisms, such as chronic sympathetic activation, upregulation of inflammatory pathways, oxidative stress and, finally, endothelial dysfunction. OBJECTIVE: We evaluated whether there is an association between OSA and coronary flow rates. METHOD: We retrospectively reviewed medical records of all patients who underwent diagnostic nocturnal polysomnography for suspected OSA. Those who had coronary angiography performed within the same year of polysomnography were divided into two main groups: those with (group 1) and without (group 2) OSA; also, angiographic coronary TIMI (thrombolysis in myocardial infarction) frame counts (TFC) were compared between the groups. Patients with coronary arterial stenosis and angiograms with inadequate filling of the coronary arteries or visualization of the distal landmarks for frame counting were excluded from the study. RESULTS: There was a statistically significant difference between the groups regarding TFCs. We found a significant positive correlation between mean TFC and apnea-hypopnea index (r=0.611, P<0.001). CONCLUSION: The current study demonstrated that sleep apnea impairs coronary flow rates and is associated with CSFP.

Is there any relationship between coronary artery disease and postprandial triglyceride levels?

OBJECTIVE: We aimed to evaluate the relationship between postprandial triglyceride (PPTG) levels and coronary artery disease (CAD). METHODS: A total of 80 patients were included in this prospective cohort study. Oral lipid loading was used in order to measure PPTG levels. In the fasting state and after the high fat breakfast, triglyceride levels were measured by enzymatic methods at 2nd, 4th, 6th and 8th hours. We made subgroup analysis to show the effects of lipid loading on triglyceride levels in patients with and without fasting hypertriglyceridemia. We evaluated triglyceride levels and changes of triglyceride levels in percentages after lipid loading using a general linear model for repeated measures. Sample size analysis was performed. RESULTS: Baseline clinical, demographic and laboratory characteristics of both groups were similar. The peak triglyceride levels were seen at the 4th hour in both groups. Triglyceride levels were significantly increased after lipid-rich-breakfast loading compared to baseline levels in both groups (p<0.001) but these changes were not significant (p=0.279). In patients with elevated fasting triglyceride levels, the area under the plasma triglyceride concentration curve was significantly larger in CAD group than control group (334±103 vs. 233±58 mg/dl, p=0.02). CONCLUSION: Our data show that in patients who have a high fasting triglyceride level, high levels of PPTG may be related to CAD, however high PPTG levels are not related to CAD in patients with normal fasting levels of triglyceride.

The clinical significance of aspirin resistance in patients with chest pain.

BACKGROUND: There are conflicting data in the literature about the clinical significance of aspirin resistance. HYPOTHESIS: We aimed to prospectively evaluate the prevalence of biochemical aspirin resistance in patients on aspirin therapy who were admitted to the emergency clinic with chest pain. We also aimed to evaluate the relation between acute coronary syndromes (ACS) and aspirin resistance. METHODS: A total of 338 patients were included in the study. Platelet reactivity was measured with the PFA-100 system (Dade Behring Inc, Deerfield, IL). Aspirin resistance determined by the PFA-100 was defined as a normal collagen and/or epinephrine closure time despite aspirin treatment (<165 s). RESULTS: Patients were divided into 4 groups: stable angina pectoris (SAP), unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), ST-elevation myocardial infarction (STEMI), and rule out ACS. Aspirin resistance was found in 81 (24%) patients in all groups. Patients with ACS had significantly more aspirin resistance than patients with rule out ACS or patients with SAP (P < .001). In the SAP group, 31 (19.6%) patients; in the UA/NSTEMI group, 19 (35.8%) patients; in the STEMI group, 14 (50%) patients; and in the rule out ACS group, 17 (17.2%) patients had aspirin resistance (P < .001). In the multivariate analysis, cardiac biomarker elevation on admission to emergency department and platelet count appeared as independent factors predictive of aspirin resistance. CONCLUSIONS: We demonstrated that incidence of aspirin resistance was significantly higher in patients who were finally diagnosed as ACS, especially in aspirin-taking patients admitted to the emergency clinic with STEMI.

The effects of short time right ventricular pacing on left atrial mechanical functions.

OBJECTIVES: Left atrium (LA) plays an important role in left ventricular filling. It is well known that right ventricular apical pacing has unfavorable effects on ventricular systolic and diastolic performance. The aim of this study is to evaluate the LA mechanical functions with 2D echocardiography in patients with a permanent pacemaker after short time ventricular pacing. DESIGN: Echocardiographic examination was performed in 38 patients (mean age 63.0+/- 10.9, 18 female) with dual chamber pacemakers or defibrillators (< 20% ventricular pacing within previous 6 months, all of them on sinus rhythm) before and after 4 hours > 90% ventricular pacing at 70 beats per minute in DDD mode with an optimal AV interval. Left atrial volumes (LAV) including at the time of mitral valve opening (Vmax), at closure (Vmin), and at the onset of atrial systole (Volp) were measured. The passive emptying, conduit, active emptying and total emptying volume, stroke volumes were also calculated. RESULTS: No significant differences were noted at baseline and after pacing for absolute Vmax, Volp, passive emptying, conduit, active emptying, total emptying volumes as well as the volumes indexed to body surface area (p >0.05). CONCLUSIONS: Short - time RV pacing seems to have no acute effects on left atrial mechanical functions.

Adenosine-induced ventricular arrhythmias in patients with supraventricular tachycardias.

BACKGROUND: Adenosine is widely used for the diagnosis and the termination of supraventricular arrhythmias. There are many case reports and few series about the proarrhythmic potential of adenosine. We sought to evaluate the proarrhythmic potential of adenosine used to terminate the supraventricular arrhythmias. METHODS: The records of all patients that received adenosine for the termination of supraventricular tachycardia were reviewed retrospectively and those with a continuous electrocardiographic (ECG) recording during adenosine administration were included to the study. RESULTS: Our search identified 52 supraventricular episodes of 46 patients with a continuous ECG recording during adenosine administration. Following adenosine administration, premature ventricular contraction (PVC) or ventricular tachycardia (VT) developed in 22 (47.8%) patients and in 26 (50%) tachycardia episodes. No patient had a sustained VT. Nonsustained VT developed in eight (17.4%) patients. All VT episodes were polymorphic, short, and self-terminating. When the basal and demographic properties of patients with PVC or VT and those without PVT or VT were compared, there was no significant difference. CONCLUSIONS: Adenosine is a quite safe and effective drug for the termination of narrow QRS complex tachycardia but it often induces nonsustained VT or PVC that are clinically insignificant in the absence of other accompanying heart disease.

Value of peri-procedural B-type natriuretic peptide levels in predicting cardiac events after elective percutaneous coronary intervention.

OBJECTIVE: B-type natriuretic peptide (BNP) has diagnostic and prognostic value in a wide variety of cardiac disorders including heart failure and acute coronary syndromes. We aimed to evaluate the prognostic value of baseline and post-procedural BNP levels in predicting major adverse cardiac events (MACE) in stable coronary artery disease (CAD) patients undergoing elective percutaneous coronary intervention (PCI). METHODS: Blood samples for BNP were obtained before, 1 hour and 24 hours after PCI of stable CAD patients who underwent elective PCI for de novo lesions in native coronary arteries. Patients were followed for 12 months for the occurrence of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, hospitalization with angina or repeat revascularization. RESULTS: Among the 95 patients with one-year follow-up data 22 had MACE. Baseline clinical and procedural characteristics of patients with and without MACE were similar. Only EF was significantly lower (P < 0.001) and complex lesion type was significantly more common in patients with MACE (P = 0.012). All measured plasma BNP levels were significantly higher in patients with MACE compared to those free of MACE (baseline P < 0.001, 1st hour P = 0.001 and 24th hour P < 0.001). Multiple logistic regression analysis identified the EF (P = 0.026) and 24th hour BNP (P = 0.002) as independent predictors of MACE. If baseline or post-PCI 1st hour BNP levels were put into analysis instead of post-PCI 24th hour BNP the predictive value of BNP lost its significance (both P > 0.05). CONCLUSION: Post-PCI 24th hour BNP is an independent predictor of MACE during 12 months of follow-up after elective successful PCI.