Fractional Exhaled Nitric Oxide Measurement in Pulmonary Hypertension: A Follow-Up Study

Pulmonary hypertension (PH) is a fatal disease although significant improvements in treatment are achieved. Easily implemented and noninvasive prognostic techniques are needed while following-up these patients. The aim was to investigate the role of fractional exhaled nitric oxide (FeNO) in follow-up for patients with PH. In this longitudinal study, patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) who were seen in PH Outpatient Clinic, Istanbul Faculty of Medicine, Istanbul University, were enrolled in the study. Echocardiography, 6-minute walking test, brain natriuretic peptide, and FeNO measurements were performed, and World Health Organization functional class was evaluated to all patients at baseline, and third, and sixth months. Right-heart catheterization and pulmonary function tests at the time of diagnosis were recorded. The study comprised 31 patients (23 women, 8 men; mean age: 53.4 ± 17.1 years) with PAH (n = 19) and CTEPH (n = 12) and 80 healthy controls. Patients with PH had lower FeNO values than the control group (16.5 ppb vs 19.8 ppb; P < .05). Fractional exhaled nitric oxide values did not change during follow-up and did not correlate with other follow-up measures except tricuspid annular plane systolic excursion values. Fractional exhaled nitric oxide was higher in the idiopathic PAH subgroup at baseline and at third month than patients with PAH associated with other diseases. Fractional exhaled nitric oxide did not change in patients who had clinical deterioration. As a conclusion; Patients with PH had lower FeNO values than healthy controls, but FeNO did not change significantly during follow-up. Large-scale studies with prolonged follow-up periods are needed to understand the role of FeNO in the follow-up of the patients with PH.

Comorbidities and their impact on chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a complex disease that is associated with devastating outcomes resulting from lung involvement and several comorbidities. Comorbidities could impact on symptomology, quality of life, the complications, the management, economic burden and the mortality of the disease. The importance of comorbidities originates from their impact on the outcome of COPD. The most frequent comorbidities in COPD are cardiovascular, endocrinological, musculoskeletal, phycological disorders and lung cancer. Almost 50% of the COPD patients have 3 or more comorbidities. The recent Global Initiative of Obstructive Lung Disease (GOLD) Guideline suggested proactive search and the treatment of the comorbidities. However, there is no certain evidence demonstrating that active treatment of comorbidities improve the outcomes of COPD. However, it is well known that several comorbidities such as cardiovascular disease and lung cancer have greater impact on mortality caused by COPD. Several studies have shown that Charlson Comorbidity index or more recenty COPD Specific Comorbidity Index (COTE) has been found to be related with mortality of COPD. This concise review intended to summarize the most frequent comorbidities in association with their impact on COPD.

Cardiotrophin-1: A new predictor of atrial fibrillation relapses after successful cardioversion

We aimed to investigate whether or not cardiotrophin-1 (CT-1) can be used as a predictor of sinus rhythm constancy in patients with atrial fibrillation (AF) converted to sinus rhythm. Thirty two patients with AF (48-78 years), without any structural heart disease were enrolled for the study. The control group consisted of 32, age and gender matched healthy persons. Measurements of CT-1 were made after transthoracic and transesophageal echocardiography prior to cardioversion (CV). Relapses of AF were investigated by monthly electrocardiograms (ECGs) and ambulatory ECGs at 1st, 3rd, and 6th month. At the end of 6th month, measurements of CT-1 were repeated. At the beginning patients with AF had increased CT-1 levels when compared to controls (0.94 ± 0.32 pg/mL vs. 0.30 ± 0.12 pg/mL, [p < 0.001]). At the end of follow-up of the 32 patients, 17 (53%) had AF relapse. Age, initial duration of AF, left ventricle diameters, ejection fraction, left atrium appendix flow rates were similar among patients with and without AF relapse. However, basal left atrium diameter (4.24 ± 0.14 cm vs. 4.04 ± 0.22 cm, p = 0.005), pulmonary artery pressure (32.82 ± 5 vs. 28.60 ± 6.23 mmHg, p = 0.004) and CT-1 values (1.08 ± 0.37 vs. 0.82 ± 0.16 pg/mL, p = 0.02) were significantly increased in patients with AF relapse. Furthermore, patients with relapsed AF had higher CT-1 levels at 6th month when compared to those in sinus rhythm (1.00 ± 0.40 vs. 0.71 ± 0.23 pg/mL). We conclude that post-CV, AF relapses are more frequent among patients with increased baseline CT-1 levels, and CT-1 may be a potential predictor of AF relapse.

Combined analysis of unipolar and bipolar voltage mapping identifies recurrences after unmappable scar-related ventricular tachycardia ablation

AIMS

Scars causing ventricular tachycardia can extend deep to and beyond bipolar low-voltage areas (LVAs) and they may be a reason for endocardial ablation failure. Analysis of endocardial unipolar voltage maps has been used to detect scar transmurality and epicardial scar. We hypothesized that endocardial unipolar LVA around the overlying bipolar LVA may predict endocardial ablation recurrence in patients with structural heart disease undergoing substrate modification.

METHODS AND RESULTS

Twenty consecutive patients with structural heart disease (11 ischaemic and 9 non-ischaemic cardiomyopathy) and undergoing substrate modification due to unmappable ventricular tachycardia (VT) (18 males, 51 ± 11 age, LVEF: 36 ± 7%) were retrospectively reviewed. Bipolar LVA defined as <1.5 mV and unipolar LVA defined as <8.3 mV, respectively, on electro-anatomic mapping system. Peripheral unipolar LVA (pUni-LVA) surrounding bipolar LVA was measured and compared patients with and without VT recurrence at 6-month follow-up period. : Mean unipolar voltage and mean bipolar voltage was 6.26 ± 4.99 and 1.90 ± 2.30 mV, respectively. Bipolar voltage and unipolar voltage in corresponding points were correlated (r = 0.652, P = 0.0001). In all patients, unipolar LVAs were larger than the bipolar LVAs. Bipolar LVA (91.1 ± 93.5 vs. 87.5 ± 47.5 cm(2), P = 0.91) and unipolar LVA (148.1 ± 96.3 vs. 104.7 ± 44.2 cm(2), P = 0.21) were similar in patients with and without VT recurrence, respectively. Peripheral unipolar LVA was significantly larger in patients with VT recurrence than without (57.0 ± 40.4 vs. 17.2 ± 12.9 cm(2), P = 0.01).

CONCLUSION

In patients with structural heart disease and unmappable VT, pUni-LVA surrounding bipolar scar predicts recurrence of VT ablation. The results of this pilot study highlight the importance of intramural/epicardial substrate on endocardial VT ablation outcome.

The relationship between T-wave peak-to end interval and ST segment recovery on intracoronary ECG during primary PCI

OBJECTIVE

T-wave peak to end interval (TPE) is a measure of repolarization dispersion, which has been reported as a major arrhythmogenic factor post acute myocardial infarction. The aim of our study was to investigate the changes in TPE in this patient population with regard to peri-procedural intracoronary ECG findings.

PATIENTS AND METHODS

Forty-four patients (34 male and mean age of 54.9 ± 10.9 years) with acute STEMI were included. Intracoronary ECG was performed during primary PCI. TPE indices were calculated before and after the procedure. Measurement of the intracoronary ST-segment was carried out before and just after coronary blood flow was established in the infarct related artery. Intracoronary ST-segment resolution (IC-STR) was defined as ≥ 1 mm compared to baseline.

RESULTS

There was no difference with respect to baseline characteristics when patients with IC-STR were compared with patients without IC-STR. TPE values decreased significantly after primary PCI in patients with IC-STR (80.9 ± 22.8 ms vs. 65.8 ± 14.4 ms; p < 0.001) whereas they did not change significantly after PCI in patients without IC-STR (79.2 ± 20.9 ms vs. 68.5 ± 16.3 ms; p = 0.18).

CONCLUSIONS

TPE measured from surface ECG recordings is significantly reduced in STEMI patients with successful reperfusion after primary PCI, as determined by IC-ECG recordings.

Effect of statins on endothelial function in patients with acute coronary syndrome: a prospective study using adhesion molecules and flow-mediated dilatation

Background

Accumulating evidence suggests that inflammatory mechanisms play a central role in the development, progression and outcome of atherosclerosis. Recent evidence suggests that statins improve anti-inflammatory, anti-thrombotic and endothelial functions, along with their lipid-decreasing effects. We examined the effect of statins on endothelial function using biochemical markers of endothelial dysfunction and brachial artery flow-mediated dilatation (FMD).

Methods

Thirty male patients presenting with acute coronary syndrome (ACS) and 26 age-matched healthy control subjects aged 40 - 60 years who were not on any medication were enrolled in the study. The patient group was started on atorvastatin (40 mg/day) without consideration of their low-density lipoprotein (LDL)-cholesterol levels. Endothelin, sICAM and E-selectin from stored serum samples were measured using commercially available enzyme-linked immunosorbant assays (ELISAs). Endothelial function was assessed using brachial artery FMD.

Results

Prior to statin treatment, E-selectin, sICAM and endothelin levels, endothelial dysfunction markers, were 99.74 ± 34.67 ng/mL, 568.8 ± 149.0 ng/mL and 0.62 ± 0.33 fmol/mL, respectively in the patient group. E-selectin and sICAM levels were significantly higher in the patients than in the control subjects (P < 0.001); however, endothelin levels were not significantly different between groups. Statin treatment significantly reduced E-selectin and sICAM levels (P < 0.001); however, the decrease in endothelin levels was not statistically significant. %FMD values were significantly increased after statin treatment (P = 0.005), and levels of C-reactive protein (CRP), an inflammation marker, were significantly reduced.

Conclusion

Our results indicate that statins play an important role in treatment endothelial dysfunction by reducing adhesion of inflammatory cells.

Usefulness of T(peak) -T(end) interval to distinguish arrhythmogenic right ventricular cardiomyopathy from idiopathic right ventricular outflow tract tachycardia

BACKGROUND

The two predominant etiologies of right ventricular tachycardia (VT) are arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathic VT arising from the right ventricular outflow tract (RVOT). Discrimination between these two entities is critical, as their prognoses and therapeutic options differ. The Tpeak -Tend (Tpe) interval reflects the transmural repolarization dispersion and its prolongation is associated with high mortality.

METHODS

We compared the sinus rhythm electrocardiogram (ECG) of 43 patients (24 male, 43 ± 16 years) with VT originating from right ventricle. Five patients under antiarrhythmic drug therapy were excluded. Tpe interval was measured in each precordial leads and compared among patients with ARVC and RVOT-VT.

RESULTS

Twenty-five patients (16 male, 42 ± 16 years) met the Task Force criteria for the diagnosis of ARVC, and 13 patients (seven male, 45 ± 14 years) had idiopathic RVOT tachycardia. Patients with ARVC had significantly prolonged Tpe intervals in all precordial leads compared to patients with idiopathic RVOT VT (137.1 ± 32.6 ms vs 93.8 ± 16.9 ms; P < 0.001 in V1, 133.2 ± 35.5 ms vs 104.7 ± 16.9 ms; P = 0.01 in V2, 125.7 ± 31.5 ms vs 99.1 ± 19.6 ms; P = 0.09 in V3, 121.9 ± 26.5 ms vs 92.3 ± 19.7 ms; P = 0.001 in V4, 123.1 ± 26.5 ms vs 99.5 ± 20:1 ms; P = 0.04 in V5 and 126.9 ± 32.2 ms vs 89 ± 11.3 ms; P < 0.001 in V6, respectively). For the diagnosis of ARVC, Tpe cut-off value of 97 ms in V1 had 84% sensitivity and 62% specificity (area under curve = 0.880).

CONCLUSION

In patients with VT of RV origin, the prolonged Tpe interval in sinus rhythm electrocardiogram supports the diagnosis of ARVC.

Aborted sudden cardiac death in a child with left ventricular non-compaction

Left ventricular non-compaction is a rare form of cardiomyopathy believed to be the result of intrauterine arrest of compaction of the endomyocardial morphogenesis, leading to persistence of the embryonic myocardium. Clinical manifestations are highly variable, ranging from no symptoms to a progressive deterioration in cardiac function that results in congestive heart failure, systemic thromboemboli, arrhythmias, and sudden cardiac death. Presented here is the case of a 4-year-old child with a history of aborted sudden cardiac death. Following resuscitation, he was admitted to the intensive care unit with neurologic sequelae that regressed later on. Transthoracic echocardiography and magnetic resonance imaging showed numerous prominent trabeculations and deep intertrabecular recesses at the apical and anterolateral region of the left ventricle. Electrophysiologic study showed polymorphic ventricular tachycardia. An implantable cardioverter-defibrillator (ICD) was implanted following clinical recovery. Five months after implantation, appropriate ICD shock due to ventricular fibrillation was documented.

Atrioventricular complete block occurring 12 years after successful ablation of slow-slow atrioventricular nodal reentrant tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most frequent form of paroxysmal supraventricular tachycardia. Selective radiofrequency (RF) catheter ablation of the slow pathway is an ideal method for treatment of patients with AVNRT. Complete atrioventricular block is a rare but serious complication of RF ablation, and primarily occurs during or immediately after the procedure. We report on a 45-year-old woman who underwent successful ablation for symptomatic AVNRT at the age of 33. She presented with paroxysmal complete AV block, which developed twelve years after RF ablation of the slow pathway and a permanent DDD pacemaker was implanted. As seen in the case we report, complete AV block complicating RF ablation can occur years after the procedure.

Relationship Between Brachial Artery Flow-Mediated Dilation, Carotid Artery Intima-Media Thickness and Coronary Flow Reserve in Patients With Coronary Artery Disease

Background

The aim of this study was to assess the relationship between brachial artery flow mediated dilation (FMD), carotid artery intima-media thickness (IMT) and coronary flow reserve (CFR) in patients with coronary artery disease (CAD).

Methods

Fifty patients with coronary artery disease, except left anterior descending artery (LAD), who showed no cardiac symptoms and 45 control subjects underwent assessment of brachial artery FMD, carotid artery intima-media thickness by high-resolution ultrasound. In addition, transthoracic second harmonic Doppler echocardiography was used to measure CFR.

Results

All of the parameters were found to be correlated with each other. CFR correlated with brachial artery FMD (r = 0.232, P < 0.05) and with carotid IMT (r = -0.403, P < 0.001). Carotid IMT correlated with brachial artery FMD (r = -0.211, P < 0.05).

Conclusion

Transthoracic CFR correlated with well-established noninvasive predictors of atherosclerosis and we suggest that it can be used as a surrogate for coronary atherosclerosis.

Brugada type 1 electrocardiogram unmasked by a febrile state following syncope

Brugada syndrome is a genetic disease characterized by persistent or transient ST elevation in the right precordial electrocardiogram (ECG) leads with or without right bundle branch block. It represents an increased risk for sudden cardiac death despite a structurally normal heart. Brugada-type ECG can be unmasked and induced by several circumstances. We report on a 24-year-old male patient who experienced a syncopal episode and manifested Brugada type 1 ECG during a febrile state. His ECG changed to normal after treatment of fever. A single-chamber ICD was implanted to the patient because of syncope, fever-induced type I Brugada ECG pattern, and ventricular fibrillation during ajmaline challenge.

Assessment of longitudinal left ventricular systolic function by different echocardiographic modalities in patients with newly diagnosed mild-to-moderate hypertension

OBJECTIVE

Standard echocardiographic methods reflect chamber dynamics and do not provide a direct measure of myocardial fiber shortening. Therefore we evaluated longitudinal left ventricular myocardial function by tissue Doppler echocardiography; strain (S), strain rate (SR), tissue Doppler velocity (TDV) in newly diagnosed mild to moderate hypertensive patients.

METHODS

Our cross-sectional and observational study population consisted of 57 patients and 48 normotensive control subjects. Patients with obesity, diabetes mellitus, regional wall motion abnormality, secondary hypertension and a history or clinical evidence of cardiovascular disease, arrhythmias or conduction abnormalities were excluded from the study. Ejection fraction, endocardial fractional shortening (eFS), meridional end-systolic stress (mESS), stress-adjusted eFS (observed /predicted eFS) were measured by M-mode echocardiography. Relationship between the left ventricular mass index and mESS was assessed by Pearson's linear regression model.

RESULTS

Hypertensive patients had significantly decreased longitudinal myocardial function compared to control subjects determined by septal (-1.25+/-0.30 vs. -1.02+/-0.33, p<0.001) and lateral (-1.20+/-0.28 vs. 1.02+/-0.41, p<0.01) SR (1/s) measurements. However, there was no significant correlation between the mESS and strain-strain rate measurements in both normal and hypertensive subjects.

CONCLUSIONS

Early impairment in longitudinal left ventricular systolic function can be expected despite normal endocardial left ventricular function indicated by M-mode echocardiography in patients with newly diagnosed and never treated mild to moderate hypertension.