Electrocardiographic alterations in patients consuming synthetic cannabinoids

INTRODUCTION

The aim of this study was to investigate the electrocardiographic parameters in patients consuming synthetic cannabinoids.

METHODS

Thirty-five patients who were consuming synthetic cannabinoids were enrolled to the study, prospectively. The control group included 35 healthy age and sex-matched volunteers. The standard 12-lead surface electrocardiograms of the study population were recorded. P maximum (P_max), P minimum (P_min), P wave dispersion, interatrial duration, P wave area in D2 derivation, abnormal P terminal force in V1 derivation, heart rate, QT interval, corrected QT, QT dispersion, PR interval duration and macrovolt T-wave alternans were evaluated by two experienced cardiologists. The intra-observer and inter-observer variations for all measurements were non-significant.

RESULTS

P_max and P_min duration was not different between the groups ( p=0.96, p=0.15, respectively). However, P wave dispersion was higher in the patient group compared to control group (34±9.4, 29.5±6.6, p=0.02, respectively). QT interval was significantly higher in the patient group than the control group (380.3±25, 365.6±22.8, p=0.01, respectively). Besides, corrected QT was higher in the patient group compared to control group (415±36.8, 392±15.5, p=0.001, respectively). QT dispersion was also higher in the patient group than the control group (39.8±10.0, 29.2±5.4, p<0.001, respectively).

CONCLUSION

Altered electrocardiography parameters linked with atrial and ventricular arrhythmia development may be observed in patients consuming synthetic cannabinoids. These patients should be evaluated regularly for cardiovascular disease and arrhythmia development. The electrocardiogram, which is a cheap and easy test to apply, can be used to determine the pro-arrythmic risk in patients consuming synthetic cannabinoids.

Quadricuspid Aortic Valve Associated with Aortic Regurgitation, Mitral Regurgitation, and Aortic Dilatation

The quadricuspid aortic valve (QAV) is a very uncommon congenital malformation with an estimated incidence of 0.003% to 0.043% of all congenital heart diseases. Combinations of QAV with several different congenital malformations have been described. The case is reported of a type A QAV associated with moderate aortic regurgitation, mild mitral regurgitation, and ascending aorta dilatation. This interesting case was referred for close follow up.

The Relationship between Pre-Infarction Angina and Serum Sphingosine-1-Phosphate Levels

BACKGROUND

Pre-infarction angina reduces myocardial infarct size by preventing the myocardium from being subjected to ischemia reperfusion (I/R) injury. Ischemic preconditioning is the proposed mechanism for this effect. Sphingosine 1 phosphate (S1P) activates ischemic preconditioning pathways and may play a role in the presence of cardioprotective effects of pre-infarction angina. Therefore, we evaluated the relationship between pre-infarction angina and serum S1P levels.

METHODS

Between May 2011 and January 2012, 79 patients with acute myocardial infarction were included in the study. In addition to taking routine medical histories, all of the patients were questioned as to whether or not they had pre-infarction angina. We determined patients serum levels of S1P at admission and discharge, and peak creatine kinase MB and troponin levels were also measured in the pre-infarction angina positive and negative groups.

RESULTS

Of the 79 patients included in the study, 36 had pre-infarction angina and 43 had not. Baseline characteristics were similar between the groups. The median level of serum S1P in patients with pre-infarction angina was significantly higher than in those without pre-infarction angina both at admission and discharge [0.54 (0.14-1.35) vs. 0.26 (0.12-0.62) p = 0.014/0.51 (0.20-1.81) vs. 0.30 (0.13-0.68) p = 0.010]. Serum high sensitive troponin levels were significantly lower in patients with pre-infarction angina [0.97 (0.39-3.07) vs. 2.56 (0.9-6.51) p = 0.034]. Serum S1P levels both at admission and discharge tended to be higher in patients with more angina episodes, but the differences between these subgroups were not statistically significant.

CONCLUSIONS

Patients who experienced pre-infarction angina had higher serum S1P levels than patients without pre-infarction angina. This study supported our hypothesis that the cardioprotective effects of pre-infarction angina may in part be mediated by S1P.

KEY WORDS

Ischemic preconditioning; Pre-infarction angina; Sphingosine 1 phosphate.

Predictability and Outcome of Vascular Complications after Transfemoral Transcatheter Aortic Valve Implantation

BACKGROUND

Although the efficacy and safety of transfemoral transcatheter aortic valve implantation (TAVI) have been improved with new devices, careful patient selection is essential and awkward complications associated with the procedure persist. Despite a gradual reduction in the delivery system size and the development of access site arterial closure devices, vascular complications remain one of the main challenges of TAVI. The aim of this single-center study was to prospectively evaluate the incidence and predictors of vascular complications in transfemoral TAVI.

METHODS

A total of 211 patients (mean age 77.98 ± 8.20 years) who underwent transfemoral TAVI between 2011 and 2014 at the authors' institution, using two different commercially available devices, was included in the study. Technical success, vascular complications, predictors of vascular complications and mortality were each assessed. Vascular complications were defined by the current Valve Academic Research Consortium-2 (VARC-2) criteria.

RESULTS

The mean logistic EuroSCORE of the patients was 21.04 ± 7.51. An Edwards SAPIEN XT valve was used in 69.7% of cases, and a Medtronic CoreValve in 30.3%. Completely percutaneous transfemoral TAVI was successful in 81.6% of patients. Procedural and 30-day mortalities were 1.4% and 8.5%, respectively. Vascular complications occurred in 16.1% of patients (minor 10.4%, major 5.7%), and necessitated surgical repair in 25 cases (11.8%). Major vascular complications were predictive of 30-day mortality (58.3% versus 5.6% (p = 0.000). Predicted major vascular complications (by multivariate analysis) were female gender (hazard ratio (HR) 5.45; 95% confidence interval (CI) 0.91-32.5, p = 0.063), arterial calcification (HR 2,88; 95% CI 1.14-7.30, p = 0.025) and sheath to iliofemoral artery ratio (SIFAR) (HR 1.91, 95% CI 1.27-2.87, p = 0.001).

CONCLUSIONS

Although vascular preclosure devices have revolutionized transfemoral TAVI, and offer a simple but effective percutaneous procedure, vascular complications are still observed in a considerable number of patients. The major vascular complications were predictive of 30-day mortality, and included female gender, iliofemoral calcification and SIFAR. Further technological and procedural developments are required to reduce vascular complication rates and related mortality.

An Extreme Case of CoreValve Bioprosthesis Embolization into the Abdominal Aorta and of the Delivery Catheter Cone into the Right Internal Iliac Artery

Transcatheter aortic valve implantation (TAVI) is a new and hopefully therapeutic option in patients with symptomatic severe calcific aortic valve stenosis and multiple comorbidities who are not eligible for open-heart surgery due to unacceptable conventional surgical risks. Herein is reported the case of a patient who underwent TAVI in whom an unusual CoreValve bioprosthesis embolization occurred into the abdominal aorta. While attempting to retrieve the whole system, the conical tip of the catheter delivery system also became embolized into the right iliac artery. Importantly, this case demonstrated a rare complication of CoreValve bioprosthesis embolization which was managed without surgical intervention. Video 1: Peripheral angiography demonstrating the embolized CoreValve bioprosthesis. Video 2: Fluoroscopy demonstrating completely opened CoreValve bioprosthesis at a level above the iliac artery bifurcation and the mobile conical tip in the valve system. Video 3: Peripheral angiography demonstrating prosthetic valve without any flow limitation and embolized conical tip into the right internal iliac artery. Video 4: Peripheral angiography demonstrating prosthetic valve without any flow limitation and embolized conical tip into the right internal iliac artery. Video 5: Aortography demonstrating the successfully implanted second CoreValve bioprosthesis in an optimal aortic position, with no paravalvular leak. Video 6: Peripheral angiography demonstrating the embolized conical tip into the right iliac artery with a normal external iliac artery flow. Video 7: Peripheral angiography demonstrating the embolized conical tip into the right iliac artery with a normal external iliac artery flow.

Relationship between serum vitamin D levels and angiographic severity and extent of coronary artery disease

BACKGROUND

Vitamin D is known for its effect in calcium and bone homeostasis. There is an increasing evidence for health benefits accomplished by activated vitamin D that go beyond these classical functions. Previous studies have suggested that lower vitamin D levels are associated with increased cardiovascular disease risk. Therefore, we aimed to evaluate relationship between vitamin D levels and extent and severity of coronary artery disease.

MATERIALS AND METHODS

A total of 746 patients in whom coronary angiography was performed between August 2012 and July 2013 were enrolled in this study. Serum vitamin D levels were measured, and patients were grouped according to their serum vitamin D levels (vitamin D <20 ng/mL (n = 602) Group 1 versus >20 ng/dL (n = 144) Group 2). Gensini score system was used to evaluate the association between serum vitamin D levels and severity and extent of coronary artery disease.

RESULTS

There was no significant difference between the groups in terms of baseline characteristics and demographic characteristics. Mean serum vitamin D levels of all patient cohort was 15.54 ± 7.46 ng/mL. Group 1 and Group 2 had an average serum vitamin D levels of 12.6 ± 3.3 ng/mL and 27.5 ± 7.8 ng/mL, respectively. Gensini score for all cohort was 26.25 ± 34.32. Group 1 had an average Gensini score of 26.4 ± 35.7; on the other hand, Gensini score was 25.5 ± 27.5 in Group 2 (P = 0.097).

CONCLUSIONS

This study failed to demonstrate significant relationship between serum vitamin D levels and the severity and extent of coronary artery disease. Further studies with more participation and homogenous groups with comparable individual and environmental features are needed to evaluate the association of serum vitamin D levels and cardiovascular diseases.

Concurrent Transcatheter Aortic Valve Implantation and Percutaneous Transvenous Mitral Commissurotomy for Totally Percutaneous Treatment of Combined Severe Rheumatic Aortic and Mitral Stenosis

Transcatheter aortic valve implantation (TAVI) is a new promising therapeutic option for patients with symptomatic severe calcific aortic valve stenosis (AS) who are inoperable or at high risk for conventional cardiac surgery. Percutaneous transvenous mitral commissurotomy (PTMC) is performed routinely in patients with severe mitral stenosis (MS) having a favorable anatomy. Although concurrent TAVI and PTMC is a theoretically possible approach in the treatment of patients with severe AS and MS who are unsuitable for conventional surgery, no cases have yet been reported in which this combined technique is used. For patients with severe AS and MS, the standard therapy is replacement of both the mitral and aortic valves. Herein are presented the details of a 52-year-old woman with urethral carcinoma, in whom simultaneous TAVI and PTMC was the chosen technique to treat combined severe rheumatic AS and MS in a single procedure.

Percutaneous Mitral Valve Repair with the MitraClip System in Mitral Regurgitation Due to Mitral Annular Calcification

Percutaneous valve repair with the MitraClip represents a new and promising therapeutic option for patients with severe mitral regurgitation (MR). Mitral valve prolapse and flail leaflet are two major causes of degenerative MR in patients who underwent the MitraClip procedure. Mitral annular calcification (MAC) is also a less-frequent cause of degenerative MR. Among patients with MAC, open surgical treatment or valvular replacement is the treatment of choice for severe MR. Herein we present a case with severe MR secondary to MAC in whom successful percutaneous valve repair was accomplished with the MitraClip system due to the high risk of open-heart surgery.

Association of serum total bilirubin level with severity of coronary atherosclerosis is linked to systemic inflammation

OBJECTIVE

Although cardiovascular protective action of bilirubin has been attributed to its antioxidant effect, there was scarce data regarding the anti-inflammatory properties. Herein, we aimed to assess the relationship between serum total bilirubin level and severity of coronary artery disease (CAD) in association with the direct inflammatory marker such as C-reactive protein (CRP), the other indirect markers included in inflammation process such as neutrophil to lymphocyte ratio (NLR) and red cell distribution width (RDW) in patients with stable CAD.

METHODS

Angiographic data of 1501 patients were analyzed in this retrospective cross-sectional study. Patients were categorized according to Gensini scores as control, mild CAD and severe CAD groups. The association of clinical and laboratory parameters with the severity of CAD were determined by multivariable linear regression analysis.

RESULTS

Total bilirubin level in the control group was significantly higher than those of the other groups. After multivariable linear regression analysis total bilirubin [β=-3.131 (-4.481, -1.782), p<0.001] was significantly associated with the severity of CAD. Futhermore, there was a moderate and significant inverse correlation between serum total bilirubin level and the severity of CAD (r=-0.173, p<0.001), CRP (r=-0.112, p<0.001), NLR (r=-0.070, p=0.026) and RDW (r=-0.074, p=0.027).

CONCLUSION

Serum total bilirubin level was independently and inversely associated with the severity of coronary atherosclerosis in patients with stable CAD. In addition, total bilirubin level was inversely correlated with CRP, NLR and RDW. These results suggest that besides its already known effect on the oxidative stress, higher serum total bilirubin level may exhibit an anti-inflammatory effect in the coronary atherosclerotic process.

Neutrophil-to-lymphocyte ratio is increased in patients with rheumatic mitral valve stenosis?

OBJECTIVE

The role of systemic and chronic inflammatory processes in the pathophysiology of rheumatic heart valve disease is well known. The neutrophil-to-lymphocyte ratio (NLR) was shown to be an indicator of systemic inflammation. In this study, we aimed to investigate relationship between NLR as a marker of systemic inflammation and rheumatic mitral valve stenosis (RMVS).

METHODS

This is a retrospective study. Among patients who underwent transthoracic echocardiography between January 2008-March 2013, 314 patients with RMVS were included retrospectively in the study. The control group included 57 healthy persons who underwent transthoracic echocardiography during the study period. Basal characteristics and NLR were compared between the two groups. Independent predictors of RMVS were determined by logistic regression analysis.

RESULTS

Basal characteristics were similar among the groups (age, 50.2 ± 14.2 vs. 49.2 ± 13.0, p=0.60). The NLR was significantly higher in patients with RMVS [2.9 (0.6-13.0) vs. 2.1 (0.7-5.8), p<0.001]. Besides, C-reactive protein (CRP) was also higher in the RMVS group [5.99 (0.3-23.7) vs. 2.98 (0.6-6.3), p=0.001]. In the regression analysis, NLR (OR: 2.24, p=0.04), CRP (OR: 1.34, p=0.03), and left atrial diameter (OR: 1.21, p=0.001) were independent predictors of RMVS. In the correlation analysis, there was a significant positive correlation between NLR and CRP (r=0.43, p<0.001).

CONCLUSION

We found that NLR was significantly increased in RMVS. Furthermore, NLR was an independent predictor of the presence of RMVS in our study population. According to these findings, NLR can be used as a predictor of RMVS. Since it is an easily available and cheap method, it can easily be used in daily clinical practice. Increased NLR can also be a sign of ongoing chronic inflammation in patients with RMVS.