Magnetic resonance imaging measurement of left ventricular blood flow and coronary flow reserve in patients with chronic heart failure due to coronary artery disease.

BACKGROUND: Coronary sinus flow reflects global cardiac perfusion and has been used for the assessment of myocardial flow reserve, which is reduced in chronic heart failure(CHF). Coronary flow reserve (CFR) can be measured by using phase-contrast (PC)velocity-encoded cine (VEC) magnetic resonance imaging (MRI). PURPOSE: To quantify and compare global left ventricular (LV) perfusion and CFR inpatients with CHF and in a healthy control group by measuring coronary sinus flow with PC VEC MRI, and to correlate this with global LV perfusion, segmental first-pass perfusion, and viability in the same patients. MATERIAL AND METHODS: Cardiac MRI was performed in 20 patients with CHF of ischemic origin and in a control group of healthy subjects (n=11) at rest and after pharmacological stress induced by i.v. dipyridamole. The MRI protocol included cine MRI, VEC MRI, first-pass perfusion, and delayed contrast-enhanced MRI for viability.Global LV perfusion was quantified by measuring coronary sinus flow on VEC MRI at rest in all subjects. CFR was determined as the ratio of global LV perfusion before and after pharmacologic stress. RESULTS: At rest, global LV perfusion was not significantly different in patients with CHF and the control group. After administration of dipyridamole, global LV perfusion and CFR were significantly lower in patients with CHF compared to the control group(P<0.001). An inverse correlation was observed between CFR and the number of infarcted and/or ischemic segments (P=0.083, P=0.037). CONCLUSION: A combined cardiac MRI protocol including function and perfusion techniques together with VEC MRI can be used to evaluate global LV perfusion and CFR in patients with CHF. Global LV perfusion and CFR measurements may have potential in the monitoring of CHF. Impaired CFR may contribute to progressive decline in LV function in patients with CHF.

Biventricular involvement in a Turkish boy with palmoplantar hyperkeratosis and curly hair, an unusual presentation of Naxos-Carvajal syndrome.

Naxos disease is an autosomal recessively inherited familial syndrome characterized by woolly hair, palmoplantar keratoderma and a cell adhesion cardiomyopathy, especially arrhythmogenic right ventricular dysplasia (ARVD). Carvajal syndrome is a variant of Naxos disease in which curly or woolly hair, biventricular--predominantly left ventricular involvement were seen. Mutations in genes encoding the cell adhesion proteins like plakoglobin and desmoplakin were related with these syndromes. We report a 17-year-old boy and his family findings with curly hair, palmoplantar hyperkeratosis, ARVD and left ventricular involvement. The family was of Arabic origin, and a third-degree consanguinity was reported between the parents. They are from east part of Turkey and there were no relatives from Cyclades Island (Greece). Patient's younger brother had ARVD without cutaneous manifestations of the syndrome and his grand father had mild ARVD, curly hair and palmoplantar hyperkeratosis.

Relation between proinflammatory to anti-inflammatory cytokine ratios and long-term prognosis in patients with non-ST elevation acute coronary syndrome.

OBJECTIVE: To investigate the relation between serum high sensitivity (hs) C reactive protein (CRP), proinflammatory cytokine concentrations, proinflammatory to anti-inflammatory cytokine ratios and long-term prognosis in patients with non-ST elevation acute coronary syndrome (NSTEACS). DESIGN: Prospective follow-up study for the first six months and then for the first year after admission to hospital. SETTING: Tertiary referral centre. PATIENTS: 80 patients (60 men, 20 women, mean age 60 (SD 10) years) with NSTEACS and moderate to high TIMI (Thrombolysis In Myocardial Infarction) risk scores. INTERVENTIONS: Blood samples from patients with NSTEACS were obtained at the time of admission. Serum concentrations of hs-CRP, (hs) pro-inflammatory (interleukin (IL) -1beta, IL-6, tumour necrosis factor alpha) and (hs) anti-inflammatory (IL-10) cytokines were analysed and proinflammatory to anti-inflammatory cytokine ratios were calculated by dividing proinflammatory cytokine concentrations by anti-inflammatory cytokine IL-10. MAIN OUTCOME MEASURE: The primary end point of the study was new coronary events (NCE) defined as the combination of cardiac death, non-fatal myocardial infarction and recurrent rest angina that required hospitalisation within 12 months of follow up. RESULTS: During the one-year follow-up period, 23 patients (29%) met the NCE criteria. Concentrations of hs-CRP, IL-1beta and IL-6 and ratios of IL-1beta:IL-10 and IL-6:IL-10 were significantly higher in patients with NCE than in patients without NCE. In the logistic regression analysis, IL-6:IL-10 ratio was the most important predictor for NCE (p = 0.006) with an odds ratio of 2.24 (95% CI 1.26 to 3.97). CONCLUSIONS: Cytokine concentrations and proinflammatory to anti-inflammatory cytokine ratios may be useful markers for predicting vascular risk in patients with NSTEACS.

Assessment of ventricular repolarization in deaf-mute children.

The long QT syndrome is a congenital disease with frequent familial transmission, characterized primarily by prolongation of the QT interval and by the occurrence of life-threatening arrhythmias. The syndrome may be familial, with or without congenital deafness, or it may be idiopathic. We attempted to assess ventricular repolarization and to identify patients with the Jervell and Lange-Nielsen syndrome among 132 deaf-mute school children. Five deaf-mute subjects had Jervell and Lange-Nielsen syndrome. The deaf-mute subjects were divided into two subgroups according to the length of their QT intervals: group 1 included 5 cases with the long QT interval (>440 msec), and group 2 included 127 subjects with the normal QT interval (< or =440 msec). Group 3 was composed of 96 control subjects. The mean QT, QTc, JT, and JTc intervals (418+/-70, 500+/-38, 302+/- 65, and 389+/-36 msec, respectively) in group 1 were significantly longer than those of group 2 (344+/-23, 408+/-22, 249+/-34, and 291+/-28 msec, respectively) and group 3 (325+/-11, 383+/-26, 228 +/-36, and 269+/-46 msec, respectively). The dispersion (d) values (QT-d, QTc-d, JT-d, and JTc-d; 63+/-10, 73+/-8, 60+/-8, and 62+/-11 msec, respectively) of group 1 were significantly longer than those of group 2 (49+/-16, 43+/-11, 48+/-21, and 45+/-18 msec, respectively) and group 3 (33+/-13, 33+/-14, 28+/-16, and 27+/-14 msec, respectively) at similar mean RR intervals. Also, the mean QT, QTc, JT, and JTc intervals and the dispersion values (QT-d, QTc-d, JT-d, and JTc-d) in group 2 were significantly longer than those of group 3 at similar mean RR intervals. Consequently, in this study, we determined that the deaf-mute children who did not meet the criteria for Jervell and Lange-Nielsen syndrome still had evidence of subtle derepolarization abnormalities evidenced by intermediate prolongation of QTc, JTc, and the corresponding measures of dispersion, and we believe an electrocardiogram examination of deaf-mute subjects will reveal this potentially life-threatening syndrome.

Echocardiographic features and QT dispersion in borderline isolated systolic hypertension in the elderly.

The aim of our study was to examine the structure of left ventricle, diastolic filling indexes and QT dispersion in elderly patients (aged 60 years and over) with borderline isolated systolic hypertension in a population screening program and to compare them with age matched controls. One hundred and four subjects (66 female, 38 male, mean age 66+/-5) and 110 normotensive age and sex matched controls (64 female, 46 male, mean age 66+/-5) were included in the study. Echocardiographic features of left ventricle, left atrium and cardiac valves, diastolic filling indexes and QT dispersion in 12 lead electrocardiographic examination were studied. In borderline hypertensive elderly, left ventricular hypertrophy was a more frequent finding compared with the controls (33% versus 15% respectively). Diastolic filling indexes were impaired, presence of left atrial enlargement and cardiac valve calcification were also more frequent in the patients group. In the electrocardiographic examination, the duration of QT and corrected QT interval and dispersion of QT and QTc were significantly prolonged compared with the controls. It is concluded that patients with borderline isolated systolic hypertension have more unfavourable echocardiographic and electrocardiographic findings compared with the normotensive elderly and especially those with end organ damage should be treated as defined for isolated systolic hypertension.

Significance of QTc prolongation on ventricular arrhythmias in patients with left ventricular hypertrophy secondary to essential hypertension.

The present study was designed to detect the arrhythmogenic effect of left ventricular hypertrophy, QTc prolongation and the relationship between the QTc duration and ventricular arrhythmias in patients with left ventricular hypertrophy secondary to essential hypertension. Sixty-eight hypertensive patients (51 male and 17 female, mean age 52+/-6 years) and 30 healthy normotensive subjects (22 male and eight female, mean age 49+/-6 years) were enrolled in the study. The frequency of ventricular arrhythmias was investigated with 24-h ambulatory electrocardiographic monitoring and grade 3 and 4 ventricular arrhythmias according to a modified Lown and Wolf classification were accepted as complex arrhythmias. The echocardiographic features of the patients were divided into five groups as follows: (1) normal left ventricular diameter and wall thickness, (2) concentric left ventricular hypertrophy, (3) asymmetric septal hypertrophy, (4) dilated left ventricle, (5) dilated and hypertrophic left ventricle. The frequency of complex ventricular ectopia and the QTc duration were estimated for each group and compared with Student's t-test. Left ventricular hypertrophy was detected in 38 of 68 patients (56%) with essential hypertension. In patients with left ventricular hypertrophy, the incidence of complex ventricular arrhythmias was two- and fivefold higher compared with patients without left ventricular hypertrophy and with controls, respectively. All of the patients with echocardiographic left ventricular dilatation had experienced complex ventricular arrhythmias. QTc duration correlated positively with left ventricular mass index and left ventricular internal diastolic dimension. The highest QTc intervals were detected in patients with left ventricular hypertrophy and complex arrhythmias. In patients with left ventricular hypertrophy, a QTc duration longer than 380 ms had a sensitivity of 74% and a specificity of 89% for detecting complex ventricular arrhythmias. It is concluded that patients with left ventricular hypertrophy have a higher incidence of complex ventricular arrhythmias and QTc prolongation in those patients can be a good marker for the increased risk of arrhythmias.

Dispersion of ventricular repolarization: a new marker of ventricular arrhythmias in patients with rheumatoid arthritis.

OBJECTIVE: To determine the value of dispersion of ventricular repolarization as a diagnostic tool to assess the risk for ventricular arrhythmias in patients with rheumatoid arthritis (RA). METHODS: We examined 42 patients with RA (age 44+/-4.8 yrs; 32 women and 10 men) and 42 age matched healthy subjects as the control group. Repolarization dispersion variables were calculated based on the difference between maximal and minimal values of QT, QTc, JT, and JTc (QTd, QTc-d, JTd, and JTc-d, respectively) from 12 lead electrocardiographic (ECG) recording at 50 mm/s. The frequency of ventricular arrhythmias by means of 24 h ambulatory ECG monitoring was investigated. A grade of > 3 ventricular arrhythmias according to modified Lown and Wolf classification was accepted as complex arrhythmias. RESULTS: We found QT and QTc intervals 392+/-20 and 409+/-38 ms in patients; values in controls were 387+/-22 and 400+/-14 ms, respectively; p > 0.05. QTd, QTc-d, JTd, and JTc-d intervals were 61.6+/-1.6, 77.6+/-1.1, 72.5+/-1.8, and 93.3+/-1.5 ms in patients and 40.3+/-0.9, 55+/-1.2, 42.6+/-0.4, and 52.9+/-0.8 ms in controls, respectively; p < 0.001. Thirty-two of the patients had complex premature ventricular complexes during 24 h ECG and the prevalence of premature ventricular complexes was found to be higher than in controls (p < 0.001). No correlation was found between complex premature ventricular complexes and QT, but there was a correlation between complex premature ventricular complexes and dispersion variables in patients with RA. CONCLUSION: Striking increases in QT dispersion indicating regional inhomogeneity of ventricular repolarization were noted in patients with RA. QT dispersion might be a useful marker of cardiovascular morbidity and mortality due to complex ventricular arrhythmias in patients with RA.

Abnormal QT dispersion in Behçet's disease.

Behçet's disease, which was originally described by Hulusi Behçet in 1937, is a generalized chronic inflammatory disease characterized by recurrent oral and genital ulcerations, ocular and dermal manifestations. Cardiac manifestations include pericarditis, myocarditis, conduction system disturbances, coronary arteritis, mitral valve insufficiency, dilated cardiomyopathy, ventricular arrhythmias and sudden cardiac death. There is little knowledge about the mechanism of ventricular arrhythmias in Behçet's disease. In this study, we examined the value of dispersion of ventricular repolarization as a diagnostic tool to assess the risk for ventricular arrhythmias and sudden cardiac death in Behçet's disease. We examined 38 patients (age: 34 +/- 4.6 years, 20F, 18M) with Behçet's disease and 30 age-matched healthy subjects were selected to serve as the control group. Repolarization dispersion parameters were calculated as the difference between maximal and minimal values of QT, QTc, JT and JTC from 12-lead ECG recordings at 25 or 50 mm/s. We found QTd, QTc-d, JTd and JTc-d intervals of 60.65 +/- 16.1, 78.45 +/- 11.4, 71.51 +/- 18.3 and 92.33 +/- 15.4 ms in Behçet's disease patients, these values in control subjects were 40.1 +/- 9.7, 56.36 +/- 7.5, 41.66 +/- 4.3 and 53.92 +/- 9.2 ms respectively (p < 0.001). Striking increases in QT and JT dispersion indicating regional inhomogeneity of ventricular repolarization were noted in patients with Behçet's disease. This new finding suggests a possible explanation for the presence of ventricular arrhythmias in patients with Behçet's disease.

Impact of hemodialysis on comprehensive ventricular repolarization.

Cardiac arrhythmia are one of the most important problems in haemodialysis patients. An important cause of the arrhythmias is inhomogenous myocardial repolarization. In this study, the ventricular repolarization parameters (QT, QTc, JT and JTc) and dispersions (d) of the parameters (QT-d, QTc-d, JT-d and JTc-d) were evaluated. Also were recorded the right-sided leads (RV3-6) and posterior leads (V7-9) in addition to the standard 12 lead ECG to assess comprehensive ventricular repolarization. The leads were divided in three groups: Group A (Standard ECG leads), Group B (Right-sided leads) and Group C (All of the leads). Among the above mentioned parameters, only JT and JTc intervals decreased significantly in all groups. There was no significant difference between the groups in evaluation of the parameters. It was concluded that in assessment of ventricular repolarization, the most important ECG intervals may be JT and JTc intervals, and the standard 12 lead ECG record is sufficient in evaluation of ventricular repolarization in hemodialysis patients.

Cardiac arrhythmias in patients on maintenance hemodialysis.

Cardiac arrhythmias were evaluated in 20 patients (14 males and 6 females; 38.2 +/- 17.6 years) undergoing regular maintenance hemodialysis (HD) for chronic and renal failure (CRF) by Holter ECG monitoring a 24-hour period. Ventricular arrhythmias (VAs) were observed in 18 of 20 patients (90%). Sporadic VAs were recorded in 75% and frequent VAs in 15% of 20 patients. It was found that VAs were correlated with an increase in duration of CRF, but there was no relation with age, duration of HD, frequency of HD, body surface area, the levels of serum sodium, chloride creatinine, phosphorous (P), magnesium, free calcium (Ca), and free fatty acids, Ca x P, cardiothoracic ratio, ejection fraction, fractional shortening, interventricular septum thickness, left ventricular wall thickness, left ventricular end-diastolic dimension and left ventricular end-diastolic index. VAs recorded frequently during HD and for 4 hours after HD. In addition, sporadic supraventricular arrhythmias (SVAs) were observed in 16 patients (80%) and frequent SVAs were recorded in 2 patients (10%). It was concluded that cardiac arrhythmias frequently developed in patients with CRF receiving HD, VAs significantly increase during HD and for 4 h after HD and frequency of VAs may be correlated with duration of CRF and the use of acetate as a buffer in the dialysate.

Echocardiography and magnetic resonance imaging of sinus of Valsalva aneurysm with rupture into the ventricle.

A 53 year-old man with rupture of sinus of Valsalva aneurysm into the right ventricle diagnosed by two dimensional echocardiography (2DE), magnetic resonance imaging (MRI), and catheterisation study is reported in this paper. Despite the fact that its incidence is low, early diagnosis is very important in this illness because of the possibility of complete cure with surgery. In this study it was shown that MRI as well as 2DE is an excellent diagnostic method for this illness. The diagnosis was also confirmed with surgery in this patient.

Significance of QT dispersion on ventricular arrhythmias in mitral valve prolapse.

The present study was designed to detect the arrhythmogenic effect of mitral valve prolapse, and the relationship between QT, QT dispersion and ventricular arrhythmias in subjects with mitral valve prolapse. Sixty-four mitral valve prolapse subjects (24 men and 40 women, mean age 27 +/- 6), and 80 healthy control subjects (32 men and 48 women, mean age 28 +/- 7) were studied. The frequency of ventricular arrhythmias by means of 24-h ambulatory electrocardiographic (ECG) monitoring was investigated. Grade > or = 3 ventricular arrhythmias according to modified Lown and Wolf classification were accepted as complex arrhythmias. The QT intervals were measured from the beginning of depolarization of the QRS complex to the end of the T wave. Using the Bazett formula, QT interval was corrected (QTc) for heart rate. QT dispersion was calculated as the difference between the maximum and minimum QT intervals on any of 12 leads. Premature ventricular complexes seemed to develop in 56 of 64 (87.5%) subjects with mitral valve prolapse. Thirty-eight of the mitral valve prolapse subjects had complex premature ventricular complexes during 24-h ECG and the prevalence of premature ventricular complexes was found to be higher than the control subjects (P < 0.001). We found QT and QTc intervals of 388 +/- 27 and 406 +/- 33 ms in mitral valve prolapse subjects, these values in control subjects were 382 +/- 18 and 402 +/- 11 ms respectively (P > 0.05). QT dispersion and QTc dispersion intervals were 71 +/- 17 and 78 +/- 19 ms in mitral valve prolapse subjects and these values were 43 +/- 16 and 52 +/- 22 ms in control subjects, respectively (P < 0.001). No correlation was found between complex premature ventricular complexes and QT, but there was a correlation between complex premature ventricular complexes and QT dispersion in the mitral valve prolapse subjects. It was concluded that QT dispersion might be a useful marker of cardiovascular morbidity and mortality due to complex ventricular arrhythmias.

The diagnostic and prognostic value of adenosine deaminase in tuberculous pericarditis.

Because of the difficulty in isolating the causative organism, pericardial tuberculosis is rarely diagnosed. Adenosine deaminase activity measured in the pericardial fluid of 108 patients was initially of undetermined origin. Subsequently, we classified five sources: (1) tuberculosis (20 cases); (2) idiopathy (82 cases); (3) neoplasia (three cases); (4) purulent bacterial infection (two cases); and (5) radiotherapy (one case). The highest mean adenosine deaminase value (126 +/- 16.68 U.l(-1) was found in group 1; other values were 29.4 +/- 8.9, 27 +/- 7.21, 29.5 +/- 13.4, 26 U.l(-1) in the idiopathy, neoplasia, purulent bacterial infection and radiotherapy groups, respectively. there was a statistically significant difference between group 1 and the other groups (P less than 0.001), indicating that the adenosine deaminase value has 100% sensitivity and 91% specificity. In addition, there was a positive correlation between high adenosine deaminase values and the development of constrictive pericarditis. In this study, two patients required pericardectomy. Therefore, the adenosine deaminase value is a significant prognostic indicator for the development of constrictive pericarditis in tuberculous pericarditis.

Cerebral dural sinus thrombosis. A case report.

Cerebral dural sinus thrombosis is an uncommon syndrome that a patient presents with severe headache, which may be associated with complex physical and neurologic findings. The authors present a thirty-two-year-old woman with severe headache, focal motor seizures, and subsequent hemiparesis when she was ten weeks pregnant, diagnosed as having a dural sinus thrombosis by magnetic resonance imaging and magnetic resonance angiography. In this report, the application of magnetic resonance techniques, including angiography to diagnose and monitor therapy for dural sinus thrombosis, is presented.

Impact of hemodialysis on QT interval.

Holter electrocardiographic recordings were performed for 24 hours in 20 patients with chronic renal failure on chronic hemodialysis to evaluate the effects of changes in serum calcium and potassium during hemodialysis period on the QT interval. Hemodialysis caused an increase in serum calcium from a predialysis value of 9.1 +/- 1.3 mg/dl to 11.5 +/- 1.2 mg/dl and a decrease in serum potassium from 5.6 +/- 1.4 mEg/L to 4.9 +/- 1.2 mEg/L. The Q-oTC interval shortened from a predialysis value of 0.240 +/- 0.0023 sec to 0.216 +/- 0.024 sec during the 5th hour of hemodialysis. The Q-eTc interval increased from a predialyse value of 0.391 +/- 0.030 sec to 0.412 +/- 0.024 sec during the 5th hour of hemodialysis. This shortening of Q-oTc interval was correlated with an increase in serum calcium and Q-eTc interval prolongation was correlated with a decrease in serum potassium. It was concluded that hemodialysis caused a lengthening of the Q-eTc interval and a shortening of the Q-oTc interval.

Hydatid cyst of the interventricular septum and contribution of magnetic resonance imaging.

Cardiac echinococcosis has not been reported frequently. Because of the risk of potentially lethal complications, early diagnosis and definitive treatment are very important. We report a case of a cardiac echinococcal cyst in the interventricular septum. The cyst that caused angina and showed ischemic changes in electrocardiogram was diagnosed by two-dimensional echocardiography and magnetic resonance imaging and was treated surgically.

Doppler evaluation of left ventricular diastolic filling in Behçet's disease.

Although cardiac involvement such as pericarditis, myocarditis, coronary arteritis and valvular disease in Behçet's disease occurs, few studies have assessed left ventricular diastolic function. This study assesses the prevalence of both systolic and diastolic left ventricular dysfunction in patients with Behçet's disease who have no clinical cardiac manifestations. Twenty-two patients (12 women and 10 men, mean age 34 +/- 2.4 years) underwent full clinical examination, electrocardiography, M-mode, two-dimensional, and Doppler echocardiography. The mean disease duration was 5 +/- 4.7 years (range, 1 month-16 years). As age and sex-matched control group of 20 healthy subjects was also studied. Prolonged isovolumic relaxation time, prolonged deceleration time, reversal of the early and late peak transmitral diastolic flow velocities, late peak transmitral diastolic flow velocities (E/A ratio) and increased atrial filling fraction were noted in five patients. It is concluded that left ventricular dysfunction occurs frequently in patients with Behçet's disease and Doppler echocardiography may be valuable in detecting diastolic filling abnormalities as an early sign of cardiac involvement.

The Jervell and Lange-Nielsen syndrome.

The association of prolongation of the QT interval with recurrent attacks of syncope, sudden death, and malignant ventricular arrhythmias is known as the long QT syndrome. The syndrome may be familial with or without congenital deafness, or idiopatic. The syndrome with deafness (Jervell and Lange-Nielsen syndrome) is inherited through an autosomal recessive mechanism. In this study, we attempted to identify patients with the Jervell Lange-Nielsen syndrome amongst 154 deaf mute school children. Two patients had a corrected QT interval of 0.52 and congenital sensorineural hearing loss with the other electrocardiographic changes characteristic of the syndrome, such as inverted or bifid T wave. There was no evidence of electrocardiographic (ECG) abnormality in family members, except only one case of parental deafness. This is the first and preliminary report that analyzed the incidence of the Jervell and Lange-Nielsen syndrome amongst 154 deaf mute school children in Turkey. Our study was conducted to identify patients with this syndrome amongst children of another deaf mute school in Turkey.