Tissue Doppler imaging in the evaluation of the left and right ventricular diastolic functions in rheumatoid arthritis

OBJECTIVE

Previous studies have reported that cardiovascular involvement in rheumatoid arthritis (RA) occurs frequently. Although ventricular functions of RA have been investigated through the standard Doppler in RA, they have yet to be investigated thoroughly by means of the relatively new and advantageous tissue Doppler imaging (TDI). The present study aims to investigate left and right ventricular functions in RA patients by means of TDI and standard Doppler echocardiography.

METHODS

A total of 60 patients with longstanding RA and 40 control subjects were included in the study and their left and right ventricular functions were assessed by standard pulsed-wave Doppler echocardiography, the color M-mode flow propagation velocity, and TDI. The left ventricular TDI was achieved at four different sites (lateral, septal, anterior, and inferior walls), while the right ventricular TDI was achieved through the tricuspid lateral annulus.

RESULTS

When compared with controls, the RA group showed that basal clinic and echocardiographic parameters, early (E) and late (A) diastolic velocities of atrioventricular valves, E/A ratio, and pulmonary venous Doppler parameters of these two groups were similar. It was determined that left and right ventricular E-wave deceleration times and isovolumic relaxation times of the RA patients were determined to have increased in comparison with those of the subjects in the healthy Control Group (P < 0.05). RA patients had significantly lower color M-mode flow propagation velocity (P < 0.05). While S' peak and E' peak, two of the left and right ventricular TDI parameters, were similar in both groups, A' peak, E'/A', and E/E' parameters in RA showed statistically significant differences in RA patients.

CONCLUSION

A comparison between age and sex of RA patients and healthy individuals revealed that left and right ventricular TDI parameters of RA patients were impaired, which led us to conclude that both of the ventricles could have been involved.

Can short-long-short sequences predict atrial fibrillation in acute inferior myocardial infarction?

Short-long-short sequences (SLSS), related to atrial ectopic beats (AEBs), predict the recurrence of atrial fibrillation (AF) in some clinical situations. We investigated whether SLSS predict the occurrence of AF in acute phase of inferior myocardial infarction (MI). In patients who developed AF AEBs were more frequent. We concluded that the presence of frequent SLSS could be predictors or preceding factors of the occurrence of AF in acute inferior MI.

Ventricular Tachycardia in Non-Compaction of Left Ventricle: Is This a Frequent Complication?

BACKGROUND

Isolated left ventricular non-compaction is the result of incomplete myocardial morphogenesis, leading to persistence of the embryonic myocardium. The condition is recognized by an excessively prominent trabecular meshwork and deep intertrabecular recesses of the left ventricle. Whether these intertrabecular recesses are a favorable substrate for ventricular arrhythmias is unclear. Some reports have found that the fatal ventricular arrhythmias may occur in approximately half of the patients. In this report we investigated about this association.

METHODS AND RESULTS

In total we evaluated a continuous series of 238 patients affected by non-compaction. Periodic Holter monitoring was performed every 6 months for 4 years. Only 11 patients had documented ventricular tachycardia, which was sustained in two cases and non-sustained in nine. In no cases we observed ventricular fibrillation.

CONCLUSIONS

Non-compaction alone does not seem to be a risk factor for malignant ventricular arrhythmias.

The use of levosimendan in comparison and in combination with dobutamine in the treatment of decompensated heart failure

Levosimendan is a new calcium sensitizer with inotropic and vasodilatory actions mediated by the sensitization of contractile proteins to calcium, opening of potassium channels and inhibition of phosphodiesterase-3. Its alternative mechanisms of action to those of other traditional inotropes provide a new approach in the management of decompensated heart failure. In contrast to dobutamine, levosimendan does not increase myocardial oxygen demand and, therefore, it is thought to have a lower potential to induce increases in myocardial ischemia and cardiac arrhythmias. The commonly used inotropic agent dobutamine increases myocardial contractility at the expense of increased myocardial oxygen consumption and, therefore, it can result in poor outcomes. Although dobutamine may also have favorable hemodynamic and symptomatic effects, levosimendan has been shown to be superior to dobutamine in increasing cardiac output and decreasing pulmonary capillary wedge pressure in patients with decompensated heart failure. In the presence of concomitant beta-blocker therapy, these favorable effects were present or even more pronounced during treatment with levosimendan, but not dobutamine. However, the mortality benefit of levosimendan observed in earlier trials has not been confirmed in recent, larger clinical trials. A distinct advantage of levosimendan over dobutamine is its prolonged hemodynamic effects, which last for up to 7-9 days. There are more data on the safety of levosimendan in ischemic patients than with any other inotropic drug and, therefore, levosimendan seems to be safe and effective in patients with ischemic heart disease when used at the recommended doses. Despite advances in heart failure therapy, many patients experience clinical deterioration, or do not respond to a single inotropic drug. Increasing evidence suggests the use of levosimendan in combination with dobutamine in patients with decompensated heart failure that is refractory to dobutamine alone.

The effect of successful electrical cardioversion on left ventricular diastolic function in patients with persistent atrial fibrillation: a tissue Doppler study

BACKGROUND

Changes in mitral inflow and pulmonary venous flow after electrical cardioversion (ECV) in patients with persistent atrial fibrillation (AF) were showed in many former studies. In our study we investigated the effects of ECV on diastolic parameters by using tissue Doppler imaging (TDI) in patients with persistent AF.

METHODS

Forty-one (24 women) consecutive patients underwent successful elective ECV for nonvalvular persistent AF, and maintained sinus rhythm for 1 month were enrolled to the study. Transthoracic echocardiography was applied to all patients before, 24 hours after and 1 month after ECV. Mitral annular TDI parameters were also measured with mitral inflow, pulmonary venous flow, and other standard echocardiographic measurements.

RESULTS

No differences in peak myocardial early velocity (Em), deceleration time of Em, and myocardial isovolumic relaxation time measured from mitral lateral annulus before, 24 hours after, and one month after ECV were found. Peak myocardial late velocity measured 24 hours after ECV increased significantly at the end of 1 month.

CONCLUSION

There were not any changes in LV diastolic function except restoration of atrial mechanical contraction following ECV in patients with persistent AF.

Permanent pacemaker lead implantation via azygous vein in a patient with silent superior vena cava syndrome

Occlusion of the superior vena cava is a rare but serious complication of transvenous endocardial pacing. We describe an unusual approach for permanent pacemaker implantation using the azygous vein in a patient with occlusion of the bilateral total subclavian and innominate veins after previous bilateral pectoral pacemaker implantation. Endocardial pacing using the azygous vein with minimal invasive thoracotomy may be a good option for patients with inaccessible subclavian route.

Atrial fibrillation after percutaneous coronary intervention: predictive importance of clinical, angiographic features and P-wave dispersion

Atrial fibrillation (AF) may occur during or after percutaneous coronary interventions (PCI). The purpose of the study was to determine the clinical, angiographic and electrophysiological predictors of AF after PCI. 225 patients undergoing PCI (mean age of 65 +/- 11 years) who had sinus rhythm (SR) before balloon inflation were taken to study. Of these 22 developed AF in catheterization laboratory after balloon inflation or in 24 h following PCI (AF group), 203 did not (SR group). The patients in AF group were older (67 +/- 9 vs. 63 +/- 8 years, p < 0.05) and their ventricular ejection fraction was lower than SR group (56 +/- 5 vs. 45 +/- 7%, p < 0.05). The P-wave dispersion was significantly higher in AF group than SR group (53 +/- 8 vs. 29 +/- 10 ms, p < 0.001). For the patients with ST elevation myocardial infarction, the time from the onset of symptoms to balloon inflation was 3.7 +/- 1.7 h in SR group. It was longer in AF group (4.1 +/- 1.8 h, p < 0.05). TIMI perfusion grades 2 and 3 were achieved in 23 of 27 patients in SR group, and 5 of 8 patients in AF group. Multivessel disease was documented in 93 of the patients in SR group, and 12 in AF group. Clinical reperfusion was thought to be established in 20 in SR group, and 4 in AF group. In conclusion, our results show the importance of clinical factors, angiographic results and P-wave analysis in prediction of AF following PCI.

Importance of initiation pattern of polymorphic ventricular tachycardia in patients with implantable cardioverter defibrillators

BACKGROUND

Stored intracardiac electrograms (ICEGs) are helpful in understanding the initiation mechanisms of sustained ventricular arrhythmias and in determining the appropriateness of the therapy delivered by implantable cardioverter defibrillators (ICDs).

AIM

We investigated the initiation pattern of sustained polymorphic ventricular tachycardia (PVT) and the features of the therapy delivered by ICDs.

METHODS

Sixty-six patients (mean age of 67 +/- 8 years) with 97 stored ICEGs showing PVT were evaluated. Cardiovascular diagnosis included coronary artery disease in 72.7% of the patients. The average left ventricular ejection fraction was 33+/-6%.

RESULTS

Nonsudden onset episodes were more common than sudden onset episodes (63 episodes, 65% vs 34 episodes, 35%, P < 0.001). More PVT episodes were required multiple shock delivery if they had nonsudden onset initiation (28.6% vs 23.6%, P < 0.01). The mean shock energy delivered for arrhythmia termination was higher in PVT with nonsudden onset (20 +/- 4 vs 14 +/- 5 J, P < 0.01).

CONCLUSIONS

The stored ICEGs demonstrate that PVT is most often preceded by ventricular ectopy. To be reverted, nonsudden onset episodes require higher levels of shock energy and more frequently multiple shock achievements than sudden onset episodes.

Detection of hibernate myocardium by 99mTc sestamibi gated SPECT during low-dose dobutamine infusion plus nitrate in patients with first acute myocardial infarction

AIM

To investigate the role of Tc-MIBI gated SPECT imaging following the administration of low-dose dobutamine plus nitrate (LDD+nitrate) in the assessment of left ventricular function and the perfusion of hibernate myocardial tissue.

METHODS

The study group comprised 29 patients diagnosed as having acute myocardial infarction. In the first month post-infarction, Tc-MIBI gated SPECT imaging was performed in all patients at rest-dobutamine stress and LDD+nitrate. Ejection fraction, end diastolic volume (EDV), end systolic volume (ESV), stroke volume, volume, extent score, and reversibility score values were calculated.

RESULTS

The findings of Tc-MIBI gated SPECT imaging following the administration of LDD+nitrate and the rest Tc-MIBI gated SPECT findings revealed that while the levels of ejection fraction (P=0.004) and reversibility score (P=0.000) increased significantly, there was a significant decrease in EDV (P=0.001), ESV (P=0.001), volume (P=0.017), stroke volume (P=0.257) and extent score (P=0.039) values.

CONCLUSION

The use of Tc-MIBI gated SPECT concomitantly with the administration of LDD+nitrate is useful in the determination of myocardial hibernation in patients with left ventricular failure following acute myocardial infarction.

Visualization of the site of the onset of ventricular depolarization by acceleration mode Tissue Doppler imaging technique

Tissue Doppler imaging (TDI) is a relatively new echocardiographic technique that shows regional myocardial wall velocities. The aim of this study was to evaluate the potential value of acceleration mode TDI technique for the visualization of the origin of ventricular activation site using the model of right ventricular pacing. Twenty-seven patients with implanted permanent pacemakers were studied by acceleration mode TDI, 4 of these patients were pacemaker dependent. Parasternal and apical chamber views were recorded on video tape by using acceleration mode TDI technique during sinus rhythm with preserved atrioventricular conduction in 23 subjects who were not pacemaker-dependent, and also during right ventricular apical pacing in VVI mode in 27 subjects in whom pacing lower rate was increased if necessary. Fifty images recorded during sinus and pacing rhythm in cineloop were examined by two independent observers who were unaware of the rhythm patterns and by the same observer on two different occasions for localizing the site of onset of ventricular acceleration. The origin of ventricular activation during sinus rhythm started at basal septal part of the ventricle and during pacing started at apical part of the ventricle was considered as correct localizations. The origin of ventricular depolarization was correctly localized for 46 of 50 images (92%) and 44 of 50 images (88%) by the first and the second observers, respectively. Concordant results between observers appeared in 48 of 50 (96%) of images. The diagnostic accuracy of the concordant results was 44 of 48 (91.6%) images. The kappa for interobserver variability was 0.77 (p<0.001), and for intraobserver variability was 0.64 (p<0.001) and 0.63 (p<0.001) for the first and the second observers, respectively. These results suggest that acceleration mode TDI can be used to detect the initial ventricular excited position and seems to have a potential value for localizing of the origin of normal or abnormal myocardial depolarization.

Long-term effects of antilipidaemic therapy on left ventricular function in patients with dyslipidaemia: multigated radionuclide ventriculography study

AIM

It has been reported that dyslipidaemia impairs left ventricular systolic (LVs) and diastolic (LVd) functions, irrespective of atherogenic effects, in the setting of coronary artery disease. The aim of the present study was to evaluate the effects of anti-lipidaemic therapy on LVs and LVd functions by means of multigated radionuclide ventriculography (RNV) in subjects with signs of dyslipidaemia and with preserved left ventricular function.

METHODS

Eighteen patients with dyslipidaemia (eight men, 10 women, mean age 50+/-10 years) were included in the study. While the clinical examination and treadmill exercise test results were normal in all patients, low-density lipoprotein levels exceeded 160 mg . dl. Patients with medical conditions including coronary artery disease, hypertension, diabetes, cardiomyopathy and valvular heart disease which would influence left ventricular function were excluded from the study. RNV was performed in all subjects, taking into account the best septal position to differentiate the left ventricle from the right ventricle. The following parameters were calculated: ejection fraction, peak ejection rate (PER), time to peak ejection (TPER), a ejection rate (aER), a ejection fraction (aEF), Peak filling rate (PFR), time to peak filling rate (TPFR), a filling rate (aFR), a filling fraction (aFF).

RESULTS

The low-density lipoprotein value decreased and the high-density lipoprotein value increased after statin therapy (P<0.001 and P<0.003, respectively). PER, aER and aFF significantly increased and TPER decreased as a consequence of statin therapy (respectively, P<0.05, P<0.05, P<0.05 P<0.05).

CONCLUSION

Anti-lipidaemic therapy is effective in dyslipidaemic patients. RNV is a useful and non-invasive method for monitoring changes in ventricular function following anti-lipidaemic treatment strategies.

Transesophageal echocardiographic diagnosis of ventricular noncompaction associated with an atrial septal aneurysm in a patient with dilated cardiomyopathy of unknown etiology

The present report discusses a case of noncompaction of the ventricular myocardium in a 51-year-old woman with dilated cardiomyopathy of unknown etiology. Multiple transthoracic echocardiography examinations had failed to show myocardial noncompaction, but subsequently performed transesophageal echocardiography clearly demonstrated the characteristic findings of this unusual disease. Also, an atrial septal aneurysm was identified by transesophageal echocardiography. Patients with cardiomyopathy of unknown origin should be investigated to define the presence or absence of myocardial noncompaction, even if transthoracic echocardiography fails to show anatomical features of this disease. The present case is the first reported case of ventricular noncompaction associated with an atrial septal aneurysm as a congenital anomaly.

Regional distribution and extent of perfusion abnormalities, and the lung to heart uptake ratios during exercise thallium-201 SPECT imaging in patients with cardiac syndrome X

BACKGROUND

Cardiac syndrome X is defined as angina-like chest pain with transient ischemic ST-segment changes during exercise and angiographically normal epicardial coronary arteries. Studies with myocardial perfusion imaging in this syndrome have indicated that some patients, but not all, have an abnormality on perfusion scan. However, the impact of these perfusion abnormalities on pulmonary thallium uptake is not clear in this group of patients.

OBJECTIVE

To evaluate the regional distribution and extent of perfusion abnormalities, and the lung to heart (L:H) uptake ratios using exercise thallium-201 single-photon emission computed tomography (TI-201 SPECT) in patients with cardiac syndrome X.

METHODS

The study group consisted of 31 selected cardiac syndrome X patients with regional perfusion abnormalities during exercise TI-201 SPECT imaging. A control group included 26 healthy subjects with normal coronary angiograms, exercise testing and exercise TI-201 SPECT imaging. Exercise TI-201 SPECT results were analyzed with further estimation of the L:H ratios, number and localization of regional perfusion defects, and their mean extent scores expressed in pixels and in per cent of the left ventricular wall. Twenty-two patients with known coronary artery disease were also included in the analysis of the L:H ratios.

RESULTS

Multiple perfusion defects were detected in 13 (42%) patients and perfusion defects of single localization were detected 18 (58%) patients. All patients had reversible perfusion abnormalities: 21 (67.7%) had anterior, 14 (45.2%) had inferior and 12 (38.7%) had lateral localization of perfusion defects. The analysis of the extent of the perfusion defects revealed that the mean scores of the extent of the single regional defects were 38.61+/-43.8 pixels and those of multiregional defects were 106.1+/-55.2 pixels, which corresponded to 6.05+/-1.8% and 16.6+/-5.4% of the left ventricular wall defects, respectively. Patients with cardiac syndrome X had a significantly higher L:H ratio during exercise than the healthy subjects (0.46+/-0.02 versus 0.34+/-0.03, P<0.01). In addition, L:H ratios were found to be higher in patients with multiple perfusion defects (0.50+/-0.02) than in patients who had only anterior (0.45+/-0.08) or inferior (0.43+/-0.02) perfusion defects (P<0.05 for both). There were no statistically significant differences in the rest L:H ratios between the study and control groups. Also, no significant differences were observed in exercise L:H ratios between the cardiac syndrome X patients and the patients with coronary artery disease (0.46+/-0.02 versus 0.49+/-0.03, P>0.05).

CONCLUSIONS

The results suggest that multiple perfusion defects in multiple vascular regions are relatively common in cardiac syndrome X patients, with the majority of these patients having at least one abnormal perfusion bed. Patients with this syndrome who have perfusion abnormalities also had significantly higher L:H ratios during exercise than did the control patients. Increased exercise L:H ratios were more prominent in patients with multiple perfusion defects.

Cigarette smoking increases plasma concentrations of vascular cell adhesion molecule-1 in patients with coronary artery disease

Cigarette smoking adversely affects endothelial function and increases risk of coronary artery disease (CAD). The pathogenesis of coronary atherosclerosis is currently thought to involve interactions between inflammatory cells and vascular endothelium. Adhesion molecules play a pivotal role in the accumulation of inflammatory cells at the endothelium. Little is known about the role of cigarette smoking in this atherosclerotic inflammatory process. The aim of this study was to evaluate the effects of cigarette smoking on the plasma concentrations of soluble vascular cell adhesion molecule-1 (VCAM-1) in patients with CAD. The soluble VCAM-1 level was quantified in smoking CAD patients (n = 19) in comparison to those from patients with CAD alone (n = 10). Plasma concentrations of soluble VCAM-1 were measured by enzyme-linked immunosorbent assay. The soluble VCAM-1 level was found significantly higher in smokers than in nonsmokers (32.1279 +/- 21.6421 vs 9.4570 +/- 7.8138 ng/mL, p < 0.01), and in patients with previous myocardial infarction (MI) than in those without previous MI, but not significant statistically (27.7279 +/- 22.8813 vs 17.8170 +/- 15.9172 ng/mL, p > 0.05). No significant difference was observed for soluble VCAM-1 levels between hypertensive and nonhypertensive patients, multivessel and one-vessel disease, or anterior and inferior MI localizations. The present study suggests that in patients with CAD, smoking leads to elevated levels of soluble VCAM-1 that may clarify one of the mechanisms of its accelerating effect on the atherosclerotic process.

Clinical importance of the initiation pattern of monomorphic ventricular tachycardia

We investigated the clinical and electrophysiological features of monomorphic ventricular tachycardia (MVT) with different initiation patterns in patients with implantable cardioverter defibrillator to assess whether there is a relationship between the initiation patterns of sustained MVT and clinical characteristics, and the efficacy of antiarrhythmic and electrical therapy. Fifty-five stored IECGs in twenty-two patients with MVT were evaluated. All MVT episodes were classified as initiating with ventricular premature beats (non-sudden onset MVT) or without ventricular ectopy preceding tachycardia (sudden onset MVT). Non-sudden onset MVT was characterized by shorter tachycardia cycle length (CL) and required higher shock energy for termination. Sudden onset MVT was precipitated by shortening of the sinus CL before tachycardia and was more common with relatively better preserved systolic function.

Electrical cardioversion of atrial fibrillation in a case of dextrocardia

Although atrial fibrillation is one of the most frequent and widespread cardiac arrhythmias, there is not sufficient data on frequency and electrical cardioversion of this arrhythmia in cases of dextrocardia. The present case report describes a 66-year-old woman with atrial fibrillation and dextrocardia who was admitted to hospital with a complaint of palpitations; no cause of the atrial fibrillation was found. Electrical cardioversion was performed for termination of the arrhythmia. By placing the anterior paddle in the right parasternal area and the lateral paddle in the area where the apex of the left ventricle palpated at the right side of the chest, cardioversion was performed and sinus rhythm was achieved.

Detection of myocardial injury after internal cardioversion for atrial fibrillation

BACKGROUND

Cardiac troponin levels do not rise to marked levels after external cardioversion of atrial fibrillation. Subsequent test discharges during implantation of cardioverter defibrillators may cause an elevation of cardiac troponin levels, but are still controversial.

OBJECTIVE

To determine whether the biomarkers of cardiac injury increase after internal cardioversion (IC) of atrial fibrillation.

METHODS

Forty-four patients with chronic atrial fibrillation were studied (mean age 59 +/-7 years). Electrode catheters were inserted through the femoral vein. One of these was positioned in the lower right atrium. A second defibrillation electrode was placed in the coronary sinus and an additional catheter was positioned in the right ventricular apex in order to obtain satisfactory R wave synchronization and to provide postshock ventricular pacing. The shocks were delivered by external defibrillator. Starting with a test shock of 1 J intensity, the energy was increased in steps (to maximum 15 J) until cardioversion was achieved. At least 1 min was permitted to elapse between unsuccessful defibrillation attempts before the next shock was applied. Blood samples for serum levels of cardiac troponin T, cardiac troponin I, creatine kinase MB and myoglobin were drawn before and 2 h, 4 h, 8 h and 24 h after IC. Each level of biomarker was compared with baseline.

RESULTS

In 40 of 44 patients, IC was successful at a mean cardioversion threshold of 7.6+/-3.3 J. Although the serum levels of these biomarkers tended to rise, marked elevation was not detected in any of samples (P>0.05 for each). There was no correlation between the levels of biomarkers and the number and energy of shocks applied. No severe complications were observed.

CONCLUSIONS

Following uncomplicated IC of atrial fibrillation, cardiac biomarkers do not rise to marked levels, which indicates that significant myocardial injury does not occur by shocks in the usual dosage.

Initiation of monomorphic ventricular tachycardia: electrophysiological, clinical features, and drug therapy in patients with implantable defibrillators

At least 2 distinct patterns of sustained monomorphic ventricular tachycardia (MVT) have been ascribed during analysis of stored intracardiac electrograms retrieved from implantable cardioverter defibrillators and Holter recordings in patients with ventricular arrhythmia. We aimed to investigate the electrophysiological features of MVT with different initiation patterns in patients with implantable cardioverter defibrillators and to assess whether there is a relationship of the initiation patterns of sustained MVT with clinical characteristics and efficacy of antiarrhythmic therapy. Seventy-four stored intracardiac electrograms in 21 patients (mean age of 68.2 +/- 4.2 years) with MVT were evaluated. Cardiovascular diagnosis included coronary artery disease in 85.7% of the patients. All MVT episodes were classified as those initiating with ventricular premature beats (nonsudden onset MVT) and those without ventricular ectopy preceding tachycardia (sudden onset MVT). There was significant difference in left ventricular ejection fraction between MVTs with different initiation pattern, being the lower in those with nonsudden onset (33.6% +/- 38.4% vs. 38.4 +/- 7.0%, P <.04). Ventricular tachycardia cycle length was shorter in group of MVT with nonsudden onset as compared with sudden onset (338.5% +/- 48.1% vs. 376.8% +/- 57.0%, P <.02). Tachycardia with sudden onset was associated with shorter preceding RR interval than tachycardia with nonsudden onset (821.8 +/- 136.2% vs. 748.7 +/- 107.7%, P <.01). There were no significant differences in the type of antiarrhythmic drug therapy used between groups (P >.05). Monomorphic ventricular tachycardias with nonsudden onset occurred more frequently than with sudden onset, without precipitating RR cycles shortening, are faster in rate, associating with lower ejection fraction. Monomorphic ventricular tachycardias with sudden onset are characterized by preceding shortening of RR intervals, slower cycle length, and less worsening of ejection fraction.

P wave amplitude and duration may predict immediate recurrence of atrial fibrillation after internal cardioversion

BACKGROUND

Although internal cardioversion (IC) for atrial fibrillation (AF) is effective at restoring sinus rhythm, immediate recurrence (IR) of AF after IC is a major and largely unpredictable clinical problem. The purpose of the study was to determine the role of P wave duration and amplitude in prediction of IR of AF after IC. Forty-five consecutive patients undergoing IC for chronic AF were evaluated.

MATERIAL AND METHODS

After successful IC, 1-minute ECG recording was obtained in all patients. P wave duration and amplitude in Lead II and V1 were measured using computer. Forty patients (88%) had successful IC. Thirteen patients experienced IR of AF within 1 minute of restoring sinus rhythm.

RESULTS AND CONCLUSION

As a result, the incidence of IR of AF after IC was higher in the patients with shorter P wave amplitude (for lead II P<0.01, for V1 P<0.01) and larger P wave duration (for lead II P<0.01, for V1 P<0.05).

Noncompaction of the ventricular myocardium: report of two cases with bicuspid aortic valve demonstrating poor prognosis and with prominent right ventricular involvement

Noncompaction of the ventricular myocardium is a rare, unclassified cardiomyopathy due to an arrest of myocardial morphogenesis. The characteristic echocardiographic findings consist of multiple, prominent myocardial trabeculations and deep intertrabecular spaces communicating with the left ventricular (LV) cavity. The disease typically involves the LV myocardium, but right ventricular (RV) involvement is not uncommon. The clinical manifestations include heart failure (HF) signs, ventricular arrhythmias and cardioembolic events. Noncompacted myocardium may occur as an isolated cardiac lesion, as well as it can be in association with congenital anomalies. We describe two illustrative cases of noncompaction of the ventricular myocardium, a 19-year-old male with bicuspid aortic valve and progressive worsening of HF, and a 61-year-old male with marked RV involvement in addition to LV apical involvement, both with the typical clinical and echocardiographic features of the disease.

Cold exposure and left ventricular diastolic performance in coronary artery disease

It is known that cold exposure is accompanied by coronary artery vasoconstriction and ischemia in patients with coronary artery disease (CAD). The aim of the present study was to evaluate the response of left ventricular (LV) diastolic and systolic functions, estimated by means of Doppler echocardiography, to cold pressor test (CPT) in patients with CAD. Twenty-five male patients (mean age 50.8 +/- 8.1 years) with documented CAD underwent CPT with Doppler echocardiographic assessment of LV diastolic and systolic functions. According to the development of ischemic response to CPT, all patients were divided into 2 groups: group 1, 10 patients with ischemia and group 2, 15 patients without ischemia during CPT. Cold exposure caused significant increase in blood pressure with no changes in heart rate in all CAD patients. Patients with signs of ischemia during cold exposure had lower transmitral flow velocity during early filling (p < 0.001), prolonged isovolumic relaxation time (p < 0.04), shortened deceleration time of early transmitral flow velocity (p < 0.001), and higher values of Doppler-derived index of myocardial performance (p < 0.0001) than those without ischemic response to CPT. Cold exposure in CAD patients through stimulating of vasoconstriction and ischemia was associated with derangements in LV myocardial performance, manifested by delayed relaxation, impaired stiffness, and reduced contractility.

Reversible myoglobinuric renal failure following rhabdomyolysis as a rare complication of cardioversion

Reversible myoglobinuric renal failure following rhabdomyolysis that was related to repeated countershocks delivered for the treatment of refractory recurrent VT and VF attacks during acute myocardial infarction is presented in this case report, in which scan with technetium-99m pyrophosphate has been used for in the diagnosis of extensive skeletal muscle damage.

Long-short sequence may predict immediate recurrence of atrial fibrillation after external cardioversion

AIM

We thought, that analysis of surface electrocardiograms recorded immediately after electrical external cardioversion (EC) might enlighten the mechanisms responsible for immediate recurrence of atrial fibrillation (AF) and especially to test whether atrial ectopic beats (PAC) with long-short (LS) sequence are related to the recurrence of arrhythmia after cardioversion in patients with chronic AF.

METHODS AND RESULTS

One hundred and thirty-seven patients (mean age 57+/-7 years) undergoing EC for chronic AF entered the study. Evaluation of the patients included clinical history, physical examination, ECG, routine laboratory tests, and transthoracic echocardiography. The cardioversion was performed with monophasic waveform shock and immediately after successful EC, 1 min of recording of the ECG lead II was analysed. One hundred and twenty patients (87%) of 137 patients enrolled in the study had had successful EC and 33 (27%) of them experienced immediate recurrence of AF within 1 min (Group I) and 87 patients had no arrhythmia recurrence (Group II). In group I in 24 patients (73%) recurrence of AF was initiated by PAC with LS sequence. In only 12 of 87 (13%) patients who did not experience immediate recurrence of AF (Group II) PACs were recorded.

CONCLUSIONS

Atrial ectopic beats (PACs) with LS sequence, being responsible for AF relapse in about 70% of patients, might predict early re-initiation of arrhythmia after EC. Electrocardiograms, recorded immediately after EC, are a potentially feasible approach in establishing the patterns of AF relapse that may be useful in the management of AF recurrence.

Combination of QT variability and signal-averaged electrocardiography in association with ventricular tachycardia in postinfarction patients

The authors investigate incidence of ventricular tachycardia/ventricular fibrillation (VT/VF) in relationship with combination of noninvasive arrhythmia risk markers as left ventricular ejection fraction (LVEF), late potentials (LP), and QT variability index (QTVI) and compare the utility of their combination in association with sustained ventricular arrhythmias in patients after myocardial infarction (MI). Fifty-four patients with old MI, among them 27 with documented spontaneous sustained VT/VF entered the study. All of them underwent evaluation for arrhythmias and noninvasive risk stratification. Logistic regression analysis demonstrated that the highest association with ventricular tachyarrhythmia had combination of LP and increased QTVI (13.8, P<.0002), followed then by combination of LVEF and LP (12.2, P<.0005), LP alone (P<.001), QTVI (P<.002) and LVEF (P<.003) alone and age (P<.01). After stepwise regression analysis showed that the model including association of LP and QTVI, age and EF is the best one for delineating patients having the risk of ventricular tachyarrhythmia development. In conclusion, patients with combination of positive LP and increased QTVI after MI have high likelihood for development of serious sustained arrhythmia.

Cardiac troponin T and cardiac enzymes after external transthoracic cardioversion of ventricular arrhythmias in patients with coronary artery disease

BACKGROUND

Serum levels of cardiac troponins after external cardioversion (ECV) for atrial fibrillation and atrial flutter are widely investigated, and no increases in cardiac troponin T (cTnT) levels have been reported. However, the effect of ECV on cardiac enzyme release may depend on the type of arrhythmias. Furthermore, ventricular tachycardia (VT) or ventricular fibrillation (VF) could cause release of cardiac enzymes after ECV due to underlying myocardial ischemia, myocardial dysfunction, or more pronounced hemodynamic deterioration during arrhythmia.

AIM

The purpose of this study was to determine whether direct current (DC) shock may increase cardiac enzyme levels in patients with coronary artery disease undergoing ECV for VT or VF, so that diagnosis of acute myocardial infarction, which initially presents with VT or VF, can be excluded.

METHOD AND RESULTS

We obtained measurement of cTnT, total creatine kinase (CK), and CK MB isoenzyme (CK-MB) activity before and after ECV in 27 patients (mean +/- SD age, 62 +/- 13 years) with induced VT or VF (22 patients) who required ECV during provocative electrophysiologic testing and who underwent ECV due to VT (5 patients) in the cardiology department. Blood samples were drawn before, and 4 h, 8 h, and 24 h after ECV. The total energy used was 630 +/- 375 J (range, 200 to 1,280 J). CK levels rose to the upper limit of reference range in seven patients (26%), and CK-MB activity was higher than the normal reference range in five patients (19%) after ECV. In contrast, cTnT concentrations remained within the normal range (< 0.1 micro g/L) in all patients. Peak CK and CK-MB activity levels strongly correlated with the total energy delivered.

CONCLUSION

Elevation of cTnT level after an urgent DC shock strongly indicates the diagnosis of acute myocardial infarction presented with life-threatening arrhythmias, rather than myocardial damage caused by ECV.

Immediate recurrence of atrial fibrillation after internal cardioversion: importance of right atrial conduction variations

This study investigates the importance of right atrial conduction features in predicting of immediate recurrence of atrial fibrillation (AF) after internal cardioversion (IC). Patients with chronic AF who were resistant to external cardioversion were studied. Twenty-four patients (16 female, 8 male mean age 58 +/- 7 years) who were successfully converted to sinus rhythm (SR) by IC, and experienced recurrence of AF within 1 minute of restoration of SR were enrolled in group A. Thirty-four patients, who were converted to SR by IC and in whom SR was maintained at least 1 minute after IC, were enrolled in group B (24 female, 10 male mean age 56 +/- 6 years) as control. There was no difference in age, left atrial diameter, use of antiarrhythmic drug, etiology and duration of AF between the groups. After successful IC, His bundle electrocardiograms via placed electrode catheters, and surface electrocardiograms were recorded for 1 minute. P-A interval duration, as a marker of right atrial conduction, was measured from the onset of the earliest registered surface P wave to the onset of the atrial deflection on His-bundle catheter recording. The difference between the recorded maximum P-A duration and minimum P-A duration obtained in 1 minute after IC was described as P-A interval absolute difference. There were no differences in the maximum P-A duration and minimum P-A duration between two groups. But, the P-A absolute difference was more pronounced in group A compared to group B (16.9 +/- 7.7 ms versus 10.3 +/- 6.4 ms, P < .001) and was significantly correlated with P wave dispersion derived from the surface electrocardiogram (r = .72, P < .001) In conclusion, variations in right atrial conduction might play an important role in predicting immediate recurrence of AF in patients converted to SR by IC.

Traumatic total occlusion of left main coronary artery caused by blunt chest trauma

Myocardial infarction is a rare complication that can occur immediately after a blunt chest trauma. We report a 36-year-old male who experienced a fatal anterolateral myocardial infarction after a nonpenetrating chest injury sustained in a car accident. Injuries of the coronary arteries associated with blunt chest trauma predominantly affect the left anterior descending artery. This is the first case of traumatic complete occlusion of the left main coronary artery (LMCA) demonstrated by coronary angiography.

Comparison of QT dispersion between primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction

BACKGROUND

Previous studies have documented that reduction in QT dispersion after thrombolytic treatment in acute myocardial infarction depends on reperfusion status as well as infarct site. Primary percutaneous transluminal coronary angioplasty as compared with thrombolytic therapy has been shown to result in higher patency rates of the infarct vessel.

OBJECTIVES

To evaluate whether primary PTCA has a more favorable effect on reducing QT dispersion in patients with acute MI as compared to thrombolytic treatment.

METHODS

The study population included 42 consecutive patients (33 men, mean age 58 +/- 11 years) with acute MI (24 anterior wall, 18 inferior wall) who were treated with primary PTCA (group A, n = 21) or thrombolytic therapy (group B, n = 21) at 3.9 +/- 2 hours after symptom onset. QT intervals were measured before and 24 hours after treatment.

RESULTS

On the admission electrocardiogram, patients with anterior MI had higher values of QT and QTc dispersions than patients with inferior MI (52 +/- 9 vs. 36 +/- 9 msec, P < 0.05 and 61 +/- 4 vs. 56 +/- 4 msec, P = 0.002, respectively). There was a significant reduction in QT and QTc dispersions from admission to 24 hours in all patients (from 50 +/- 9 to 37 +/- 9 msec, P < 0.001 and from 59 +/- 5 to 42 +/- 5 msec, P < 0.001, respectively), and also in group A (from 49 +/- 8 to 32 +/- 5 msec, P < 0.001 and from 58 +/- 5 to 38 +/- 3 msec, P < 0.001, respectively) and in group B patients (from 51 +/- 10 to 42 +/- 10 msec, P < 0.01 and from 60 +/- 4 to 46 +/- 5 msec, P < 0.001, respectively). QT and QTc dispersions were found to be shorter in group A at 24 hours after treatment than in group B (32 +/- 5 vs. 42 +/- 10 msec, P < 0.001 and 38 +/- 3 vs. 46 +/- 5 msec, P < 0.001, respectively).

CONCLUSIONS

Reperfusion therapy with primary PTCA or thrombolytic agents reduces QT and QTc dispersions in acute MI. QT and QTc dispersions after reperfusion treatment are shorter with primary PTCA than with thrombolytic therapy.

Evaluation of C-reactive protein, fibrinogen and antithrombin-III as risk factors for coronary artery disease

BACKGROUND

Inflammation is an important feature of atherosclerotic lesions and increased production of the acute-phase reactant. The contribution of coagulation factor to the development of coronary artery disease has not yet been clearly established.

OBJECTIVES

To test whether C-reactive protein, fibrinogen and antithrombin-III are associated with angiographic CAD, history of myocardial infarction and extensive atherosclerotic involvement.

METHODS

Blood samples were tested for CRP, fibrinogen and AT-III levels from 219 individuals undergoing coronary angiography.

RESULTS

CRP was higher in patients with CAD (0.95 +/- 1.31, n = 180, vs. 0.39 +/- 0.61 mg/dl, n = 39, P < 0.0001) and in those with a history of MI (1.07 +/- 1.64, n = 96, vs. 0.65 +/- 0.72 mg/dl, n = 84, P < 0.05) than in control subjects. The patients who developed unstable angina had higher CRP levels than the patients with stable CAD (2.07 +/- 2.38, n = 7, vs. 0.80 +/- 1.13 mg/dl, n = 173, P < 0.001). Fibrinogen was significantly higher in patients with CAD than in those without CAD (298 +/- 108 vs. 258 +/- 63 mg/dl, P < 0.01). In patients with CAD, mean AT-III value was less than in patients without CAD, but this difference was not statistically significant (P = 0.08). No difference was found in CRP, fibrinogen and AT-III values among the patients with single, double or triple vessel disease.

CONCLUSIONS

CRP is elevated in patients with CAD and a history of MI. Elevated levels of CRP at the time of hospital admission is a predictive value for future ischemic events. There is an association between higher levels of fibrinogen and CAD. The association of AT-III levels with CAD needs testing in further studies.