Effects of hormone replacement therapy on heart rate variability in postmenopausal women

BACKGROUND

Hormone replacement therapy (HRT) is associated with reduced cardiovascular risk, but the underlying mechanism(s) are not fully understood. This study investigated the effects of a 6-month course of HRT on cardiac autonomic function parameters assessed by heart rate variability (HRV) in postmenopausal women.

METHODS

Forty-six healthy postmenopausal women (age 48 +/- 5, range 40-60) with normal baseline electrocardiogram and negative exercise testing were enrolled. HRT, which was either 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate or 0.625 mg/day CEE alone were administered depending on hysterectomy status. Power spectral analysis of HRV was performed to calculate the low frequency component in absolute (LF) and normalized units (LF nu), high frequency component in absolute (HF), and normalized units (HF nu), and the LF/HF ratio. The standard deviation of RR intervals (SDNN) was calculated from the time series of RR intervals.

RESULTS

A 6-month course of HRT did not significantly alter resting heart rate (P > 0.05). The LF/HF ratio and LF nu significantly decreased after HRT (P = 0.022 and P = 0.032), whereas a significant increase was noted in the HF component of HRV (P = 0.043), indicating an improvement in cardiac autonomic function. The SDNN value, which was 28.8 +/- 11.8 ms before HRT significantly increased to 35.4 +/- 16.7 ms after 6 months (P = 0.011).

CONCLUSION

Our results indicate that a 6-month course of HRT may significantly improve cardiac autonomic function parameters, a finding that could at least partly explain the potential cardioprotective effect(s) of HRT.

Intraperitoneal involvement in rhabdomyosarcoma CT findings in a child

Intraperitoneal neoplastic involvement in rhabdomyosarcoma is rare and its incidence and imaging characteristics need to be further described. We present the computerized tomography (CT) findings of a case with pelvic rhabdomyosarcoma and intraperitoneal neoplastic involvement. Enhanced peritoneal and retroperitoneal masses were seen around the liver, spleen, in the paracolic gutters, and in the lesser sac without evidence of ascites, mesenteric nodules or omental caking. Our case also showed that absence of ascites does not preclude the presence of peritoneal involvement. Progression in the peritoneal disease was also well demonstrated by CT.

Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular risk in patients with polycystic ovary syndrome

OBJECTIVE

To assess cardiac flow parameters in patients with polycystic ovary syndrome (PCOS).

DESIGN

A prospective case-control study.

SETTING

University-based hospital.

PATIENT(S)

Thirty consecutive patients with PCOS were enrolled. Thirty women with regular menstrual cycles served as the controls.

INTERVENTION(S)

Systolic and diastolic function parameters were assessed by standard two-dimensional and M-mode echocardiography. Insulin sensitivity was evaluated by a standard 75-g oral glucose tolerance test and area-under-curve insulin analysis. Serum hormones, lipid profile, homocysteine, vitamin B(12), folate, fibrinogen, uric acid, and plasminogen activator inhibitor-I concentrations were measured.

MAIN OUTCOME MEASURE(S)

Systolic and diastolic function parameters, insulin sensitivity and serum homocysteine levels.

RESULT(S)

The mean serum homocysteine and uric acid concentrations were significantly higher in the PCOS group. Patients with PCOS had significant hyperinsulinemia. All systolic function parameters were comparable between the two groups. However, patients with PCOS had significantly lower peak mitral flow velocity in early diastole and significantly lower ratio between the early and late peak mitral flow velocities and also had significantly longer isovolumic relaxation time, reflecting a trend for nonrestrictive-type diastolic dysfunction. The area-under-curve insulin correlated positively with peak mitral flow velocity in late diastole (r = 0.375). The mean cholesterol/high-density lipoprotein ratio correlated negatively with mean mitral flow velocity in early diastole (E) peak (r = -0.474). The mean fasting insulin level correlated negatively with mean E/A ratio (r = -0.387).

CONCLUSION(S)

Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular disease risk in patients with PCOS.

Extent of coronary atherosclerosis and homocysteine affect endothelial markers

The aim of the study was to evaluate the effects of the presence, extent, and clinical stability of coronary artery disease on endothelial function parameters, C-reactive protein and homocysteine levels. Fifty-eight patients with angiographically documented coronary artery disease and 25 patients with normal coronary arteries were evaluated for risk factors, plasma homocysteine, C-reactive protein, and soluble adhesion molecule levels. Vascular cell adhesion molecule-1 and sE-selectin were significantly higher in the group with coronary artery disease than in healthy subjects (p = 0.005 and p = 0.031, respectively). Patients with unstable angina had significantly higher C-reactive protein (p < 0.001), troponin I (p < 0.01), and leukocyte counts (p < 0.05) than those with stable angina. sE-selectin levels were correlated with the extent of coronary atherosclerosis (r = 0.444, p < 0.05), and plasma homocysteine levels were associated with vascular cell adhesion molecule-1 (r = 0.479, p < 0.05) in unstable cases. These results suggest that vascular cell adhesion molecule-1 and sE-selectin are useful for determining the presence of coronary atherosclerosis, whereas C-reactive protein, troponin 1, and leukocyte count are predictors of clinical stability.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Hormone replacement therapy shortens QT dispersion in healthy postmenopausal women

BACKGROUND

The aim of the study was to investigate the effects of hormone replacement therapy (HRT) on myocardial repolarization characteristics in postmenopausal women without coronary artery disease.

METHODS

Fifty-one consecutive healthy postmenopausal women (age 48 +/- 5) with negative exercise stress testing were prospectively enrolled into the study. Standard 12-lead electrocardiograms were obtained to evaluate the effects of 6 months of HRT on QT intervals, corrected QT intervals (QTcmax and QTcmin), QT dispersion (QTd), and corrected QTd (QTcd). Hormone regimens were continuous 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate (MPA) or 0.625 mg/day CEE alone depending on the hysterectomy status.

RESULTS

Although not statistically significant, CEE alone or in combination with MPA increased QTmax and QTmin values. However, the increase in QTmin was greater than the increase in QTmax, which resulted in statistically significant shortening of QTd (P = 0.007 in CEE and P < 0.001 in CEE + MPA groups). There was a significant prolongation of QTcmin values after 6 months in patients assigned to the CEE group (P = 0.001). The QTcd values were significantly shortened by HRT with both regimens (for CEE group 49 +/- 13 ms vs 38 +/- 13 ms, P = 0.01; for CEE + MPA group 49 +/- 14 ms vs 36 +/- 13, P < 0.001).

CONCLUSION

HRT significantly decreased the QTd and QTcd in postmenopausal women without coronary artery disease, independent of the addition of MPA to the regimen. This improvement in myocardial repolarization may be one of the mechanisms of the favorable effects of HRT on cardiovascular system. However, the clinical implications of the shortening of QTd in postmenopausal women with HRT must be clarified.

What is the optimal evaluation time of the QT dispersion after acute myocardial infarction for the risk stratification?

The sequential changes of the corrected QT dispersion (QTcD) were studied in 136 patients 1 day to 30 days after a transmural acute myocardial infarction (AMI) to investigate the optimal measurement time of QT dispersion for risk stratification. The study group included 136 patients (89 men; mean age, 57+/-10 years) with transmural AMI who were treated with thrombolytics (Tr+ group, n = 73) or not (Tr- group, n = 63) and 65 healthy controls (43 men; mean age, 56+/-7 years). Fourteen patients in whom ventricular tachycardia (VT), ventricular fibrillation (VF), or sudden cardiac death developed during the 30-day period were also evaluated as major cardiac arrhythmia (MCA) group. ECGs were obtained for each patient on days 1, 3, 5, 10, 15, and 30 after AMI. QTc dispersion in patients with AMI (for every period of QTcD after MI) was significantly more prolonged than in normal controls (49.3+/-16.3 ms) (p<0.001). QTcD was significantly greater in patients without thrombolytics than in patients with thrombolytics for every period (days 1, 3, 5, 10, 15, and 30) of QTcD after MI (p<0.001). The mean of QTcD was significantly greater in patients with MCA than in patients without MCA group for every period (days 1, 3, 5, 10, 15, and 30) of QTcD after MI (p < 0.05). Maximal QTcD was seen on day 10 (p < 0.05 1st vs day 10 for each group) after myocardial infarction, and then reached a plateau for an each group. The ideal time to measure the QTD for risk stratification is at least 10 days after AMI.

Mature ovarian teratoma as a possible cause of fever and clinical exacerbation in Behçet's disease: a case report

Abstract Behçet's disease (BD) is a chronic relapsing systemic vasculitis of unknown etiology. BD is very rarely associated with neoplastic diseases. We report the case of a 39-year-old woman who had been treated for BD for 3 years. She presented with relapsing oral and genital lesions and persistent high-grade fever which had lasted for 1 month. The possible cause of the exacerbation of BD and fever in this patient was a mature ovarian teratoma. To our knowledge this is the first report of a patient with BD associated with a ovarian teratoma.

The World Survey of Cardiac Pacing and Implantable Cardioverter Defibrillators: calendar year 1997--Europe

The registry of the European Working Group on Cardiac Pacing (EWGCP) is based on the European Pacemaker Identification Card originally designed in July 1978. National registration centers collect the local data and send aggregated annual data to the EWGCP. For 1997, data were obtained from 2,887 hospitals in 20 European countries representing a population of 568 million. Across all participating countries, the median value for all implanted pacemakers was 378 per million population. For initial pacemaker implants, the median value was 290 per million population. Single chamber atrial pacing was important in Denmark, the Netherlands, Poland, Slovak Republic, Spain, and Sweden for the treatment of sick sinus syndrome. Dual chamber pacing accounted for < 50% of initial implants in only 5 of 14 countries for atrioventricular block, and in only 3 of 15 countries for sick sinus syndrome. In 7 of 15 countries, unipolar ventricular leads were used in > or = 50% of cases. In 6 of 14 countries, there was > 15% use of unipolar atrial leads. Nine of 13 countries frequently used atrial active-fixation leads. For the 1997 survey, ICD data were obtained from 16 countries. The total number of ICDs per million population was a median value of 14. Initial ICD implants per million population was 11. Only 3 of 16 countries implanted a total of 30 or more ICDs per million population. Pacing and ICD practices were dependent on the availability of medical and technical resources and influenced by economic constraints inherent in health care administration and insurance coverage patterns.

Intrapancreatic duodenal duplication cyst with inversion of the superior mesenteric vessels: CT findings

We present a case of intrapancreatic duodenal duplication cyst and inversion of the superior mesenteric vessels. CT findings of this association are discussed.

Hepatic artery aneurysm in a patient with Behçetś disease and segmental pancreatitis developing after its embolization

Segmental pancreatitis is an unusual form of acute pancreatitis mostly seen in the head of pancreas. We present the CT findings of a segmental pancreatitis in the body and tail of the pancreas developed following endovascular embolization of a giant hepatic artery aneurysm and arterioportal fistula in a patient with Behçet's disease.

Effects of stent coating on platelets and endothelial cells after intracoronary stent implantation

BACKGROUND

Adhesion molecules are known to be important in the regulation of endothelial cell and platelet functions. Increased platelets P-selectin expression is a marker of stent thrombosis after uncoated stent placement.

HYPOTHESIS

The aim of this study was to compare the effects of intracoronary placement of phosphorylcholine (PC)-coated, versus heparin-coated, versus uncoated stents on platelets and endothelial activity.

METHODS

Thirty patients (age 55 +/- 10, 27 men) with significant proximal left anterior descending coronary artery stenoses were randomized to elective implantation of PC-coated, versus heparin-coated, versus uncoated stents. Following stent placement, intravenous heparin and aspirin plus ticlopidine were administered. Venous plasma soluble E-selectin, sP-selectin, and intercellular adhesion molecule-l levels were measured before the procedure and 24 and 48 h thereafter as markers of platelet and endothelial cell activation. Patients were excluded if they had a disease known to influence platelet and endothelial cell function.

RESULTS

Plasma sP-selectin levels decreased significantly after implantation of PC- and heparin-coated stents (p = 0.04), but remained unchanged in patients randomized to uncoated stents. Plasma sE-selectin levels increased significantly after uncoated stent placement (p = 0.04) and remained unchanged after coated stent implantation.

CONCLUSION

In patients treated with combined antiplatelet therapy, implantation of PC- and heparin-coated stents decreased platelet activity without activating endothelial cells, whereas placement of uncoated stents led to endothelial activation without changing platelet activity. These results suggest that PC-coated and heparin-coated stents may be advantageous in limiting thrombotic complications.

MR imaging of pelvic and thigh muscles in congenital muscular dystrophy

To define and compare the magnetic resonance (MR) imaging findings of pelvic and thigh muscles in merosin-deficient and merosin-positive congenital muscular dystrophy, 10 patients with merosin-positive and six patients with merosin-deficient muscular dystrophy were examined in a 0.5 T MR imaging unit. Intensity and atrophy scores were given to individual muscles by two radiologists and were calculated for three muscle groups (pelvic, anterior thigh and posterior thigh muscles). Rectus femoris was affected less than the vastus muscles in 40 percent of cases in merosin-positive patients, whereas there was no selective sparing in merosin-deficient patients. Sartorius and gracilis were relatively spared in both groups. The most consistently affected muscles were gluteus maximus, adductor magnus and brevis in merosin-positive patients. Atrophy was more prominent in the adductor muscles in the merosin-deficient group. Intensity scores of anterior thigh muscles of the merosin-positive group were significantly higher than those of the merosin-deficient group (U = 8, p = 0.016). When stepwise logistic regression model was applied, intensity score of the anterior thigh muscles was found to be the best differentiating variable. The regression analysis model formed was able to differentiate the two forms with a sensitivity of 80 percent and specificity of 83 percent.

Merosin-deficient congenital muscular dystrophy with mental retardation and cerebellar cysts unlinked to the LAMA2, FCMD and MEB loci

We report a case of congenital muscular dystrophy with secondary merosin deficiency, structural involvement of the central nervous system and mental retardation in an 8-year-old girl from a consanguineous family. She had early-onset hypotonia, generalized muscle wasting, with weakness especially of the neck muscles, joint contractures, mental retardation and high creatine kinase. Muscle biopsy showed dystrophic changes with partial deficiency of the laminin alpha(2) chain. Cranial magnetic resonance imaging revealed multiple small cysts in the cerebellum, without cerebral cortical dysplasia or white matter changes. The laminin alpha(2) chain (6q2), Fukuyama type congenital muscular dystrophy (9q31-q33) and muscle-eye-brain disease (1p32-p34) loci were all excluded by linkage analysis. We suggest that this case represents a new entity in the nosology of congenital muscular dystrophy.

P wave dispersion in hypertensive patients with paroxysmal atrial fibrillation

It is important to assess the risk of developing paroxysmal atrial fibrillation (PAF) in hypertensive patients since hypertension is a common disorder predisposing to PAF. We sought to determine if patients with hypertension at risk of PAF can be identified while in sinus rhythm by measurements of P wave dispersion. Twelve-lead surface electrocardiograms were recorded in 44 hypertensive patients with history of PAF (group I, mean age = 60) and in 50 hypertensive patients without history of AF (group II, mean age = 57). The maximum P wave duration, the minimum P wave duration, and P wave dispersion (Pd = Pmax - Pmin) were calculated from 12-lead surface ECGs. Left atrial dimension (LAD) and left ventricular ejection fraction (LVEF) were measured by echocardiography. P wave dispersion was significantly greater in group I than group II (50 +/- 12 vs 38 +/- 8 ms, P = 0.001). P minimum (75 +/- 13 vs 87 +/- 11 ms, P = 0.001) and LVEF (0.63 +/- 0.05 vs 0.67 +/- 0.04, P = 0.03) were significantly lower in group I than group II. However P maximum and LAD were not significantly different in group I than group II (P > 0.05). In univariate analysis, P minimum, P wave dispersion, and LVEF were significant predictors of PAF, whereas only P wave dispersion remained a significant independent predictor of PAF in a multivariate analysis. Measurement of P wave dispersion in sinus rhythm may be a useful noninvasive clinical tool to identify patients with hypertension at risk of developing atrial electrical instability and atrial fibrillation.

Major determinants of the carotid intima-media thickness in type 2 diabetic patients: age and body mass index

The present study has been designed to quantify and compare right and left carotid intima-media thicknesses (IMT) in type 2 diabetics and healthy controls. It was also intended to investigate the effects of various risk factors on the carotid IMT in these subjects. A total of 122 subjects; 70 patients with type 2 diabetes and 52 non-diabetic subjects as controls, were recruited for the study. Right and left common carotid artery stiffness indices were assessed with ultrasonography in both groups. Age, body mass index (BMI), duration of diabetes, cigarette smoking, lipid profile including lipoprotein a, Chlamydia pneumonia seropositivity, glycemic indices, fasting insulin levels, serum fibrinogen levels and presence of hypertension, coronary artery disease, degenerative complications of diabetes mellitus were all assessed in order to define their role as determinants of carotid artery IMT. The difference between the groups regarding mean carotid IMT was statistically significant for the left carotid arteries (p = 0.028) and borderline significance was found for the right carotid arteries (p = 0.055). Age has a very strong association with carotid IMT in diabetic patients (p < 0.0001) with univariate analysis. According to the results of multivariate analysis, age and BMI were found to be the most important independent determinants of carotid IMT for both sides. When age was excluded from the model, BMI and coronary artery disease were found to have strong association with IMT on the right (p = 0.0036 and 0.0249) and BMI was the only significant determinant for the left side (p = 0.0025). This study shows that carotid IMT is greater in diabetic subjects compared with healthy controls. For the diabetic subjects, age, BMI and presence of coronary heart disease have a strong influence on the atherosclerotic process of the carotid arteries.

QT dispersion as a predictor of arrhythmic events in patients with ankylosing spondylitis

OBJECTIVE

The aim of the study was to evaluate QT dispersion (QTd), an indicator of repolarization heterogeneity, and its relation to ventricular arrhythmias in patients with ankylosing spondylitis (AS).

METHODS

A full history, clinical examination, electrocardiograms and 24-h Holter monitoring were performed in 88 AS patients and 31 volunteers of similar age and sex. Groups were compared based on electrocardiographic abnormality, QTd, arrhythmias and heart blocks.

RESULTS

QTd and corrected QTd (QTcd) were significantly greater in AS patients than controls (QTd, 52.8 +/- 15.1 vs 35.5 +/- 8.9 ms, P: < 0.0001; QTcd, 60.3 +/- 16.1 vs 39.4 +/- 10.7 ms, P: < 0.0001). The magnitudes of these parameters were associated with the duration of the disease (QTd, r = 0.56, P: < 0.01; QTcd, r = 0.60, P: < 0.001). The frequency of ventricular extrasystoles was found to be correlated with QTd (r = 0.35, P: < 0.01) and QTcd (r = 0.33, P: < 0. 01).

CONCLUSION

Involvement of the heart may be seen in AS during the early clinical course of the disease. QTd may give clues about the presence of arrhythmias and can be used as a new technique for the evaluation of asymptomatic patients. Earlier detection of cardiac involvement could alter the prognosis of the patients.

T wave alternans can decrease after coronary revascularization

Clinical observations and animal experiments indicate that T wave alternans (TWA) is associated with an increased propensity for ventricular fibrillation, and thus it may be considered as a noninvasive marker of life-threatening ventricular arrhythmias. There is substantial evidence indicating that TWA is an intrinsic property of ischemic myocardium. This study was performed to determine the role of percutaneous transluminal coronary angioplasty (PTCA)-induced myocardial ischemia in the development of TWA and the effects of revascularization. The authors recorded bipolar X, Y, and Z leads of 111 consecutive patients (mean age: 56 years) undergoing PTCA before, during, and 24 hours after the procedure. T wave alternans signal was calculated in 97 patients (43 left anterior descending, 26 right coronary artery, and 28 circumflex or major obtuse margin branch) by fast Fourier transformation technique after signal processing. Twenty-four hours after the procedure, the mean and peak X, Y, and Z values for TWA had all been significantly reduced from baseline and during balloon inflation (p<0.01). The findings point out that induced ischemia could be a trigger for T wave alternans, and successful revascularization can reduce alternans.

P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation

The prolongation of intraatrial and interatrial conduction time and the inhomogeneous propagation of sinus impulses have been shown in patients with atrial fibrillation. Recently P wave dispersion (PWD), which is believed to reflect inhomogeneous atrial conduction, has been proposed as being useful for the prediction of paroxysmal atrial fibrillation (PAF). Ninety consecutive patients (46 men, 44 women; aged 55 +/- 13 years) with a history of idiopathic PAF and 70 healthy subjects (42 men, 28 women; mean age 53 +/- 14 years) were studied. The P wave duration was calculated in all 12 leads of the surface ECG. The difference between the maximum and minimum P wave duration was calculated and this difference was defined as P wave dispersion (PWD = Pmax-Pmin). All patients and controls were also evaluated by echocardiography to measure the left atrial diameter and left ventricular ejection fraction (LVEF). There was no difference between patients and controls in gender (P = 0.26), age (P = 0.12), LVEF (66 +/- 4% vs 67 +/- 5%, P = 0.8) and left atrial diameter (36 +/- 4 mm vs 34 +/- 6 mm, P = 0.13). P maximum duration was found to be significantly higher in patients with a history of PAF (116 +/- 17 ms) than controls (101 +/- 11 ms, P < 0.001). P wave dispersion was also significantly higher in patients than in controls (44 +/- 15 ms vs 27 +/- 10 ms, P < 0.001). There was a weak correlation between age and P wave dispersion (r = 0.27, P < 0.001). A P maximum value of 106 ms separated patients with PAF from control subjects with a sensitivity of 83%, a specificity of 72%, and a positive predictive accuracy of 79%. A P wave dispersion value of 36 ms separated patients from control subjects with a sensitivity of 77%, a specificity of 82%, and a positive predictive accuracy of 85%. In conclusion, P maximum duration and P wave dispersion calculated on a standard surface ECG are simple ECG markers that could be used to identify the patients with idiopathic paroxysmal atrial fibrillation.

Assessment of autonomic nervous system functions in patients with vitamin B12 deficiency by power spectral analysis of heart rate variability

The purpose of this study was to test the autonomic nervous system function of patients with vitamin B12 deficiency (megaloblastic anemia) by measuring heart rate variability (HRV). The study population consisted of 17 vitamin B12 deficient patients and 15 age- and sex-matched normal volunteers. HRV was measured by power spectral analysis from which power of the low frequency (LF) peak (0.04-0.15 Hz), normalized units of the LF peak (LFNU), power of the high frequency (HF) peak (0.15-0.4 Hz), normalized units of the HF (HFNU), and ratio of power of LF to power of HF (LF:HF) were calculated. Vitamin B12 deficient patients had lower LF, LFNU, HF, HFNU, and LF:HF ratio than normal volunteers (P < 0.05). Decreases in sympathetic indices (LF and LFNU) were greater than those measured in parasympathetic indices (HF and HFNU). All HRV parameters correlated positively with the level of vitamin B12 (P < 0.001) and negatively with the duration of disease (P < 0.001). After vitamin B12 replacement the HRV parameters of patients and controls became comparable (P > 0.05). Our data suggest that autonomic sympathetic and parasympathetic nervous activities are decreased in patients with vitamin B12 deficiency, an abnormality that can be corrected by vitamin B12 replacement therapy.

Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature

Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.

Inappropriate shocks diagnosed by stored electrograms of implantable cardioverter defibrillators--two case reports

An implantable cardioverter defibrillator is an important therapeutic option for patients with high risk of life-threatening ventricular arrhythmias. However, their use is also associated with several complications including inappropriate shock. Although the most frequent cause of inappropriate shock is supraventricular tachyarrhythmias, lead fracture can also be associated with inappropriate shock. Diagnosis of lead fracture can be made by chest x-ray radiography, fluoroscopic examination, interrogation of the device, and intracardiac electrograms. In this report, the authors present two cases of inappropriate shock due to lead fractures in the costoclavicular region that could only be diagnosed by the help of stored intracardiac electrograms. Methods for diagnosis of lead fractures and modalities to avoid recurrences are also discussed.

MR imaging of the kidneys after laparoscopic cryoablation

OBJECTIVE

We describe the MR imaging findings of patients who underwent laparoscopic renal lesion cryoablation.

MATERIALS AND METHODS

Twenty-one patients (men, 11; women, 10; age range, 36-84 years; average age, 65.5 years; SD, 11.9) with 23 small renal masses (< or =4 cm) underwent laparoscopic renal lesion cryoablation. Twenty patients (22 masses) underwent follow-up MR imaging on the first day after surgery, 12 (13 masses) at 1 month, 16 (18 masses) at 3 months, 14 (15 masses) at 6 months, and 12 (12 masses) at 12 months. Three radiologists retrospectively reviewed MR images for the signal intensity, characteristics, and size of cryolesions. CT-guided needle biopsy was performed 6 months after cryoablation (18 patients) and no evidence of malignancy was discovered.

RESULTS

Including all lesions at all times on T1-weighted images, cryolesion signal intensity was isointense to renal parenchyma (47/76, 61.8%) or isointense with hyper- or hypointense foci (7/76, 9.2%). On T2-weighted images, almost all lesions (72/76, 94.7%) were isointense or hypointense, and there was a hypointense rim between the cryolesion and renal parenchyma in 38.2% of lesions (29/76). A thin peripheral rim of enhancement was noted in 19.7% (14/74) of lesions. Cryolesions decreased in size an average of 61.5% (SD, 22.82; n = 12) at 1 month, 78.7% (SD, 13.5; n = 17) at 3 months, 83.5% (SD, 24.3; n = 15) at 6 months, and 94.2% (SD, 8.1; n = 11) at 1 year after cryoablation (one patient was not scanned 1 day after cryoablation and was not included in our calculations).

CONCLUSION

After renal cryoablation, MR imaging revealed common signal characteristics such as low-signal-intensity rims on T2-weighted images, enhancement patterns such as thin peripheral rims, and interval size changes.

Delayed posttraumatic adrenal hematoma

Posttraumatic adrenal hemorrhage is a frequent finding after severe abdominal trauma and can have important clinical implications if it is bilateral. With the increased use of helical CT in the evaluation of trauma patients, posttraumatic adrenal hematoma is more frequently diagnosed. We present the CT findings of a unilateral posttraumatic adrenal hemorrhage where the diagnostic findings only appeared in the follow-up study. We think that mild enlargement of the adrenal gland in a trauma patient can be an early sign of an impending adrenal hemorrhage.

Focal inflammatory diseases of the liver

Inflammatory lesions constitute an important subgroup of focal liver lesions. They may mimic primary or metastatic neoplastic lesions and their differentiation from neoplasia is clinically very important since management of the patient significantly changes. Radiologists should have an important role in both the diagnosis and therapy of these lesions by performing percutaneous aspirations and drainages. In this review we discussed the radiological findings of pyogenic abscesses, amebic abscesses, candidiasis, tuberculosis, hydatic cysts, fascioliasis, ascariasis, schistosomiasis, and sarcoidosis with a special emphasis on US, CT and MR characteristics.

Assessment of autonomic nervous system function in patients with Behçet' s disease by spectral analysis of heart rate variability

The purpose of this study was to evaluate the autonomic nervous system (ANS) function in patients with Behçet's disease by using power spectral analysis of heart rate variability (HRV). The study population consisted of 71 patients with Behçet's disease, and 26 normal volunteers. HRV was measured by power spectral analysis in supine and standing position. In supine position, Behçet's patients had increased low frequency component in absolute (LF) and normalized units (LF nU) but had lower values of high frequency component in absolute (HF) and normalized units (HF nU) than the controls (P < 0.05). In standing position, higher values were obtained in LF and LF nU but lower values of HF and HF nU in Behçet's patients than controls (P < 0.05). LF/HF was significantly higher in patients both in supine (2.5 +/- 1.0 vs. 1.2 +/- 0.8, P = 0.001) and standing (21.9 +/- 7 vs. 1.8 +/- 0.3, P < 0.001) positions. Our data suggest that patients with Behçet's disease may have asymptomatic ANS dysfunction, which is in the form of increased sympathetic and decreased parasympathetic modulation, and power spectral analysis of HRV is beneficial in assessing the ANS function.

Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial

BACKGROUND

Bolus fibrinolytic therapy facilitates early efficient institution of reperfusion therapy. Tenecteplase is a genetically engineered variant of alteplase with slower plasma clearance, better fibrin specificity, and high resistance to plasminogen-activator inhibitor-1. We did a double-blind, randomised, controlled trial to assess the efficacy and safety of tenecteplase compared with alteplase.

METHODS

In 1021 hospitals, we randomly assigned 16,949 patients with acute myocardial infarction of less than 6 h duration rapid infusion of alteplase (< or = 100 mg) or single-bolus injection of tenecteplase (30-50 mg according to bodyweight). All patients received aspirin and heparin (target activated partial thromboplastin time 50-75 s). The primary outcome was equivalence in all-cause mortality at 30 days.

FINDINGS

Covariate-adjusted 30-day mortality rates were almost identical for the two groups--6.18% for tenecteplase and 6.15% for alteplase. The 95% one-sided upper boundaries of the absolute and relative differences in 30-day mortality were 0.61% and 10.00%, respectively, which met the prespecified criteria of equivalence (1% absolute or 14% relative difference in 30-day mortality, whichever difference proved smaller). Rates of intracranial haemorrhage were similar (0.93% for tenecteplase and 0.94% for alteplase), but fewer non-cerebral bleeding complications (26.43 vs 28.95%, p=0.0003) and less need for blood transfusion (4.25 vs 5.49%, p=0.0002) were seen with tenecteplase. The rate of death or non-fatal stroke at 30 days was 7.11% with tenecteplase and 7.04% with alteplase (relative risk 1.01 [95% CI 0.91-1.13]).

INTERPRETATION

Tenecteplase and alteplase were equivalent for 30-day mortality. The ease of administration of tenecteplase may facilitate more rapid treatment in and out of hospital.

Effects of stroke localization on cardiac autonomic balance and sudden death

BACKGROUND AND PURPOSE

Stroke has been shown to alter autonomic function. The purpose of this study was to show the differential effects of stroke localization on autonomic function parameters assessed by heart rate variability (HRV).

METHODS

To determine the differential effect of ischemic stroke localization on autonomic cardiac innervation, we evaluated 62 patients with ischemic stroke and 62 age- and sex-matched controls. The localization of the infarct was determined by CT and MRI. Power spectrum analysis of HRV was performed. Myocardial necrosis was ruled out by echocardiography and creatine kinase myocardial isoenzymes measurements.

RESULTS

All stroke patients had significantly decreased low frequency, high frequency, and standard deviation of all relative risk intervals values (P<0.001). However, patients with right-middle cerebral artery (R-MCA) and insula lesions had significantly lower power spectrum analysis values compared with all other localizations (P<0.001). In addition, 5 patients with R-MCA insular lesions died suddenly compared with 2 patients with left-middle cerebral artery insular lesions during hospitalization. Both sympathetic- and parasympathetic-controlled HRV were decreased in patients with ischemic stroke. The most pronounced decrease was found in the territory of R-MCA insular cortex, which suggests that cardiac autonomic tone may be regulated by insula and that these patients are more prone to cardiac complications such as arrhythmias and sudden death due to autonomic imbalance.

CONCLUSION

We conclude that stroke in the region of insula (especially the right) leads to decreased HRV and to increased incidence of sudden death.

Prediction of atrial fibrillation recurrence after cardioversion by P wave signal-averaged electrocardiography

The purpose of this report was to determine prospectively whether P wave signal-averaged electrocardiography (ECG) is useful for the prediction of recurrences of atrial fibrillation after cardioversion. The P wave signal-averaged ECG was recorded in 73 patients after successful cardioversion. Duration of the filtered P wave and the root mean square voltages for the last 20 ms of the P wave were calculated. In addition to signal-averaged ECG P wave analysis, all patients were evaluated by echocardiography. During 6 months follow-up period recurrence of atrial fibrillation was observed in 31 (42.5%) patients and in 42 (57.5%) patients sinus rhythm was maintained. There was no difference in gender, age, presence of organic heart disease, left atrial diameter, left ventricular ejection fraction, use of antiarrhythmic drug, and duration of atrial fibrillation (P>0.05). The filtered P-wave duration was longer and the root mean square voltages for the last 20 ms of the P wave was lower in patients with recurrence of atrial fibrillation than in patients who maintained sinus rhythm (138.3+/-12.5 ms vs. 112.4+/-11.8 ms, P = 0.001; 1.9+/-0.7 microV vs. 2.5+/-0.6 microV, P = 0.001). A filtered P-wave duration > or =128 ms associated with a root mean square voltage for the last 20 ms of the P wave < or =2.1 microV had a sensitivity of 70% and specificity of 76% for the detection of patients with recurrence of atrial fibrillation after successful cardioversion of atrial fibrillation. We found that the likelihood of recurrence of atrial fibrillation after cardioversion was increased 4.31-fold (95% confidence interval 2.08-9.83) if these parameters were used. These results suggest that P wave signal-averaged ECG could be useful to identify patients at risk for recurrence of atrial fibrillation after cardioversion.

MR characteristics of oxidized cellulose (Surgicel)

OBJECTIVE

Oxidized regenerated cellulose (Surgicel) is one of the most commonly used bioabsorbable topical hemostatic agents. Surgicel may mimic an abscess on both CT and sonography when a patient undergoes imaging early in the postoperative period. The objective of our study was to describe the appearance of Surgicel on postoperative MR imaging.

CONCLUSION

Surgicel has a short relaxation time on T2-weighted images, resulting in low signal intensity in the early postoperative period. MR imaging may be helpful in differentiating Surgicel from an abscess and therefore in preventing unnecessary attempts at aspiration.

Atrial fibrillation after coronary artery bypass surgery: P wave signal averaged ECG, clinical and angiographic variables in risk assessment

BACKGROUND

Atrial fibrillation (AF) is a commonly encountered arrhythmia and occurs in up to 40% of patients after coronary artery bypass surgery (CABG). The preoperative signal averaged ECG (SAECG) P wave may be useful indicator of AF after CABG. We prospectively analyzed the predictive value of SAECG P wave compared to clinical variables.

METHODS

Fifty-three patients with coronary artery disease undergoing first elective CABG were enrolled. All patients had P wave specific SAECG, standard 12 lead ECG, ejection fraction and left atrial posteroanterior diameter from the echocardiogram within the 24 h before surgery. From the SAECG P wave, filtered P wave duration was measured. Lead II P wave duration, left atrial enlargement and left ventricular hypertrophy were determined from standard ECG. Patients were continuously monitored during their postoperative period and serial ECGs were taken.

RESULTS

During an observation period of up to 16 days, 19 (35.8%) patients developed AF 2.8+/-1.3 days after CABG. Patients with AF more often had left atrial enlargement (LAE) on ECG (P = 0.041) and right coronary artery (RCA) lesion (P = 0.0034). The filtered P wave duration on the SAECG was significantly longer in the AF patients than those without AF (129.7+/-13.2 ms versus 113.9+/-9.0 ms, P = 0.001). Logistic regression analysis identified independent predictors, estimated adjusted relative risk (95% confidence interval) of AF: with LAE, the relative risk was 2.72 (1.13-5.82), RCA lesion, the relative risk was 3.06 (1.45-6.45) and SAECG P wave duration >122.3 ms, the relative risk was 4.58 (2.11-9.97). The occurrence of AF was predicted by electrocardiographically determined left atrial enlargement with a sensitivity of 36%, specificity of 88%, positive predictive accuracy of 63%, negative predictive accuracy of 71%. If presence of right coronary artery lesion was evaluated these values were 63%, 79%, 63%, 79% subsequently. P wave duration >122.3 ms had a sensitivity of 68%, specificity of 88%, positive predictive accuracy of 76%, negative predictive accuracy of 83%. If both P wave >122.3 ms and presence of right coronary artery lesion were combined, these values were 47%, 94%, 81%, 76% subsequently.

CONCLUSION

The predictors of AF after CABG were left atrial enlargement on standard 12 lead ECG, RCA lesion and SAECG P wave duration. Among these predictors, SAECG P wave duration was the best predictor of AF after CABG.

Increased QT dispersion in the absence of QT prolongation in patients with Behcet's disease and ventricular arrhythmias

In Behcet's disease, prominent clinical manifestations include involvement of mucocutaneous, ocular, gastrointestinal, respiratory, neurologic, urogenital, articular and cardiovascular systems. Patients with Behcet's disease have higher incidence of ventricular arrhythmia than healthy subjects. However there is a little information about the mechanism of ventricular arrhythmias in Behcet's disease. The aim of the study was to investigate whether dispersion of ventricular repolarisation was an arrhythmogenic mechanism. QT dispersion parameters were measured in 73 Behcet patients and QT dispersion was defined as the difference between the maximum and minimum QT interval in any of the 12 leads of surface electrocardiogram. Corrected QT dispersion for heart rate was calculated by Bazett's formula. The results were compared with the data from 51 matched controls without a history of cardiac disease. We found QT dispersion was greater in Behcet patients (58+/-12 vs. 37+/-8 ms, P=0.001) as was corrected QT dispersion (81+/-14 vs. 52+/-11 ms, P=0.001). There was no significant difference in minimum or maximum QT intervals between Behcet patients and controls (P>0.05). We found a correlation between QT dispersion and grade of premature ventricular complexes (r=0.7, P=0.002). Our findings suggest that increased dispersion of repolarisation may account for the development of ventricular arrhythmias in Behcet's disease.

Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study

BACKGROUND

Dual therapy with ticlopidine and aspirin has been shown to be as effective as or more effective than conventional anticoagulation in patients with an optimal result after implantation of intracoronary metallic stents. However, the safety and efficacy of antiplatelet therapy alone in an unselected population has not been evaluated.

METHODS

Patients were randomized to conventional anticoagulation or to treatment with antiplatelet therapy alone. Indications for stenting were classified as elective (decided before the procedure) or unplanned (to salvage failed angioplasty or to optimize the results of balloon angioplasty). After stenting, patients received aspirin and either ticlopidine or conventional anticoagulation (heparin or oral anticoagulant). The primary end point was the occurrence of bleeding or peripheral vascular complications; secondary end points were cardiac events (death, infarction, or stent occlusion) and duration of hospitalization.

RESULTS

In 13 centers, 236 patients were randomized to anticoagulation and 249 to antiplatelet therapy. Stenting was elective in 58% of patients and unplanned in 42%. Stent implantation was successfully achieved in 99% of patients. A primary end point occurred in 33 patients (13.5%) in the antiplatelet group and 48 patients (21%) in the anticoagulation group (odds ratio=0.6 [95% CI 0.36 to 0.98], P=0.03). Major cardiac-related events in electively stented patients were less common (odds ratio=0.23 [95% CI 0.05 to 0.91], P=0.01) in the antiplatelet group (3 of 123, 2.4%) than the anticoagulation group (11 of 111, 9.9%). Hospital stay was significantly shorter in the antiplatelet group (4.3+/-3.6 versus 6. 4+/-3.7 days, P=0.0001).

CONCLUSIONS

Antiplatelet therapy after coronary stenting significantly reduced rates of bleeding and subacute stent occlusion compared with conventional anticoagulation.

Prediction of restenosis after successful percutaneous coronary angioplasty by dobutamine thallium-201 scintigraphy

We evaluated the accuracy of dobutamine thallium-201 myocardial perfusion scintigraphy in predicting restenosis after successful percutaneous coronary angioplasty. Restenosis is one of the most important problems in patients who have undergone percutaneous coronary angioplasty. Exercise thallium-201 myocardial perfusion scintigraphy has been a well accepted non-invasive method to predict the restenosis of the dilated vessel after percutaneous coronary angioplasty, however, the role of thallium-201 myocardial perfusion using dobutamine, as a substitute for exercise in patients unable to exercise, in predicting restenosis is not well known. Therefore, 34 consecutive patients underwent dobutamine tomographic (single photon emission computed tomography) thallium-201 myocardial perfusion scintigraphy following a total of 37 successful angioplasties. No serious side effects during dobutamine infusion occured. The interval between percutaneous coronary angioplasty and scintigraphy ranged between 8 weeks to 2 years. All patients underwent control angiography within one month following myocardial perfusion scintigraphy. Sensitivity, specificity and accuracy of dobutamine myocardial imaging for predicting restenosis were 76%, 79% and 77%, respectively. Sensitivity and specificity related to the vascular territories were: left anterior descending artery 66-69%, left circumflex artery 75-100%, right coronary artery 83-66%, respectively. In conclusion, our findings demonstrating high accuracy of dobutamine myocardial single photon emission tomography for angiographic restenosis suggest its usefulness as a non-invasive tool in the follow-up of percutaneous coronary angioplasty patients.

Imaging of pancreatic transplantation using portal venous and enteric exocrine drainage

OBJECTIVE

We describe the normal radiologic appearance of pancreatic allografts transplanted using portal venous drainage with enteric drainage of exocrine secretions. We also describe the radiologic appearance of postsurgical complications.

MATERIALS AND METHODS

Of 56 patients who received pancreatic transplants using the portal-enteric technique, 24 patients subsequently required radiologic examination for suspected complications involving the pancreatic allograft. Twenty-three patients underwent CT scanning; a total of 58 CT scans were obtained. Nine abdominal sonograms were obtained in five patients, and one patient underwent angiography. The radiologic appearance of each transplant and the complications were analyzed retrospectively and correlated with the clinical course.

RESULTS

The most common indications for CT scanning were fever, elevated levels of serum amylase, and evaluation or follow-up of fluid collections. CT showed the normal and abnormal anatomy of the allograft. Abnormal findings seen in the 58 CT scans included fat stranding (30 scans), ascites (21 scans), peripancreatic fluid or pseudocyst (13 scans), and heterogeneity of the allograft (five scans). One patient had pancreatic infarction with pneumatosis and pneumoperitoneum. The allograft was obscured by bowel gas on three sonograms. Four sonograms showed no abnormalities (one Doppler sonogram showed the arterial supply and venous drainage), and one sonogram showed a pseudocyst. In the one patient who underwent angiography, imaging showed no arterial blood flow to the transplant.

CONCLUSION

Pancreatic transplantation with portal venous drainage and enteric drainage of exocrine secretions and the complications of such transplantation were revealed with CT, sonography, and angiography. Knowledge of normal anatomic configuration will allow proper interpretation of normal and abnormal findings.