Does endoscopic thoracic sympathectomy through clipping procedure have early effects on electrocardiographic parameters?

Background & objectives:

Hyperhidrosis is a pathologic condition of excessive sweating in amounts greater than physiologic needs. Endoscopic thoracic sympathectomy (ETS) is a globally accepted treatment modality for primary palmar and axillary hyperhidrosis. ETS also has distinctive effects on the heart, circulatory and respiratory systems. In this study early effects of ETS on electrocardiographic (ECG) parameters of hyperhidrosis patients were evaluated.

Methods:

Twelve-lead ECGs were performed on 72 patients who were free from cardiovascular, metabolic, neurological and pulmonary diseases and underwent planned ETS because of hyperhidrosis, before and after the procedure within the first 24 h. Heart rate (HR), PR, QT, corrected QT (QTc), QTc/Tpeak-Tend (TpTe) intervals, P-wave and QTc/TpTe dispersions were compared by ECG.

Results:

A total of 72 patients (24.1±6.0 yr, 17 female) were included in the study. The pre-operative HR of patients was significantly higher than post-operative HR of patients (73.8±12.8 vs. 68.1±12.6 beats/ min; P<0.001). The QTc dispersion (QTcd) durations of pre-operative patients were significantly longer than those of post-operative patients (51.5±6.3 vs. 44.9±5.6 msec; P<0.01). The TpTe dispersion value of pre-operative patients was significantly (P<0.001) higher than that of post-operative patients.

Interpretation & conclusions:

Our study showed that ETS through clipping procedure had positive effects on the mechanisms of arrhythmia by reducing HR, QTcd, TpTe and TpTe dispersion parameters of ECG in early periods in hyperhidrosis patients.

A Very Rare Case of Co-Existence of Cor Triatriatum Sinister and Left Pulmonary Vein Atresia

Cor triatriatum sinister (CTS) is a rare congenital abnormality. Clinical presentation of patients with CTS mainly depends on the anatomic features of membrane and may vary from mild or moderate symptoms mimicking mitral stenosis to more severe and complicated cardioembolic stroke or a new onset heart failure. We herein have reported on a young male who presented with the signs and symptoms of mitral stenosis and was diagnosed as CTS with gradient on the orifice of the membrane after transthrocacic echocardiography. Computerized tomographic angiography revealed that the patient had unilateral, left sided pulmonary arterial hypoplasia and pulmonary vein atresia, with only the right pulmonary veins draining into the left atrial chamber. Further cardiac imaging by either computed tomography or magnetic resonance imaging is necessary in order to seek accompanying cardiac and vascular abnormalities. Patients with CTS have improved short and long term survival rates if CTS and accompanying abnormalities are surgically treated before the disease is complicated with heart failure, pulmonary hypertension, stroke and etc.

Assessment of cardiac autonomic functions by heart rate recovery indices in patients with myocardial bridge

BACKGROUND

Heart rate (HR) recovery (HRR) reflects autonomic activity and predicts cardiovascular events. The aim of this study was to assess HRR in patients with myocardial bridge (MB).

METHODS

Medical recordings of 93 patients with MB and appropriate age, compared to 78 sex-matched healthy subjects were analyzed. MB was diagnosed via coronary computed tomography angiography after a positive exercise stress test (EST). HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during EST.

RESULTS

HRR1 (30.2 ± 13.3 bpm vs. 35.8 ± 10.4 bpm, p = 0.001) and HRR2 (52.3 ± 13.3 bpm vs. 57.1 ± 11.6 bpm, p = 0.013) were lower in patients with MB. In addition, HRR1 was lower in patients with left anterior descending (LAD) MB than non-LAD MB (28.5 ± 13.2 vs. 37.1 ± 11.4, p = 0.013). Presence of MB, deep MB, LAD MB and multi-vessel MB were predictors of HRR1 (p < 0.01 for all). In a multivariate analysis, LAD MB was the only significant independent predictor of HRR1 (b = -8.524, p = 0.009).

CONCLUSIONS

Patients with MB have impairment in HRR indices which is more pronounced among patients with LAD MB. Cardiac autonomic dysfunction in MB might be due to recurrent myocardial ischemia.

Effective Valsalva maneuvering during TCCD and unrevealed etiology of RLS

Either transcranial color-coded Doppler (TCCD) or contrast echocardiography (CE) is the bests of clinically applicable and reproducible methods to evaluate the functionality of right-to-left shunts that can be found in different localization on atrial septum. As the anatomical features of right-to-left shunts could vary in many forms, detection of RLS by functional tests may aid the clinician to do risk prediction and management of patients. Sensitivity of TCDD or CE can be increased by performing effective Valsalva maneuvering during the test procedure. Timing of RLS during the cardiac cycles may help interpreting about the etiology of RLS, atrial septum or intrapulmonary shunts. Intrapulmonary shunts have been recently reported to be associated with RLS and frequently overlooked unless the tests prolonged up to 10th cardiac beat. Migraine, cryptogenic strokes, and paradoxic embolism are closely associated with RLS which should be evaluated by the collaboration of cardiologists and neurologists. Success of diagnostic procedure depends on high suspicion of index for RLS and application of contrast-enhanced tests that are effectively performed at each step.

The Effects of Female Sex Hormones on Ventricular Premature Beats and Repolarization Parameters in Physiological Menstrual Cycle

BACKGROUND

The effects of gender difference on cardiac electrophysiology have been well studied. In this study, we aimed to evaluate the effects of estradiol and progesteron changes occuring in physiological menstrual cycle on ventricular premature beats (VPBs) and cardiac repolarization parameters.

METHODS

Women of reproductive age with VPBs were included into the study group and healthy women were recruited as the control group. During the menstruation period, a 12-lead electrocardiography, blood samples, and 24-hour rhythm Holter were applied to the study group. Similarly, all tests were repeated in the estimated ovulation period (12-14 days before menstruation) by all cases.

RESULTS

The study group consisted of 20 women patients with VPB, and the control group of 18 healthy women. While the number of VPB in the menstruation period was 210 beats/day (interquartile range [IQR]: 1,144), it decreased to 86 beats/day (IQR: 251) in the ovulation period with statistical significance (P < 0.05). Average heart rate in the menstruation period was 81.4 ± 10 beats/min and it significantly increased to 84.6 ± 8 beats/min in the ovulation period (P < 0.05). There were no differences in cardiac repolarization parameters in both menstruation and ovulation periods between the study and control groups. Comparing the menstruation and the ovulation periods, J-Tpeak interval, which reflects early repolarization, was shorter in the ovulation period (193 ± 27.7 ms and 201.1 ± 28.6 ms, respectively; P < 0.05). Other repolarization parameters did not show any significant difference.

CONCLUSION

VPB frequency decreases with estradiol peak in the ovulation period. This suggests that estrogen may have protective effects against ventricular arrhythmias.

Can a novel scoring system derived from hemodynamic and anthropometric variables predict sympathetic drive in young patients?

AIM

Sympathetic overdrive is generally the main pathophysiological abnormality in cardiovascular disease. However, its grading is not easy in clinical practice because of its complex interactions and differences in phenotypical expression. We proposed an easy, feasible, and global scaling system for sympathetic activity level. 'Sympathetic activity index' (SAI) is based on scores of heart rate, BMI, and blood pressure categories, which are the major representatives of sympathetic activity.

MATERIALS AND METHODS

Respectively, 1, 2, and 3 points were determined for heart rate below 69, 70-89, and above 90 bpm; -1, 1, and 2 points for BMI less than 20, 20-24.9, and at least 25 kg/m; and 1, 2, and 3 points for normal, prehypertension, and hypertension categories. Demographic and echocardiographic parameters, and left ventricular (LV) mass and mass indexes (LVMIBSA and LVMIHeight) of 545 young males were compared among groups with SAI 1-8.

RESULTS

We observed that LVM, LVMIBSA, and LVMIHeight, left atrial diameter were significantly increased in association with SAI (P<0.001). SAI was correlated with LVM (R=0.314, P<0.001), LVMIBSA (R=193, P<0.001), and LVMIHeight (R=0.316, P<0.001). SAI of at least 5.5 could determine the left ventricular hypertrophy with a sensitivity and a specificity of 57 and 70%, respectively (AUC=682, 95% confidence interval 0.610-0.753, P<0.001).

CONCLUSION

Integration of clinical, anthropometric, and hemodynamic variables in a novel index such as SAI may provide an objective and noninvasive means of grading actual sympathetic drive. SAI may be used to follow-up sympathetic activity and to predict clinical events in the management of young patients with cardiovascular and metabolic abnormalities.

Carbon monoxide poisoning increases Tpeak-Tend dispersion and QTc dispersion

Objective

Carbon monoxide (CO) poisoning leads to cardiac dysrhythmia. Increased heterogeneity in ventricular repolarisation on electrocardiogram (ECG) shows an increased risk of arrhythmia. A number of parameters are used to evaluate ventricular repolarisation heterogeneity on ECG. The aim of our study is to investigate the effect of acute CO poisoning on indirect parameters of ventricular repolarisation on ECG.

Methods

Sixty-seven patients were included in this case–control study. Thirty patients with acute CO poisoning were assigned to group 1 (19 females, mean age: 30.8 ± 11.3 years). A control group was formed with patients without known cardiac disease (group 2, n = 37; 25 females, mean age: 26.0 ± 5.2 years). Twelve-lead ECG and serum electrolyte levels were recorded in all patients. Also, carboxyhaemoglobin (COHb) levels were recorded in group 1. T_peak–T_end (T_pT_e) interval, T_pT_e dispersion, T_pT_e/QT ratio, QT interval and QT_d durations were measured as parameters of ventricular repolarisation. Corrected QT (QT_c) and QT_c dispersion (QT_cd) intervals were determined with the Bazett’s formula.

Results

The mean COHb level in group 1 was 27.6 ± 7.4% and mean duration of CO exposure was 163.5 ± 110.9 min. No statistically significant difference was found in age, gender, serum electrolytes or blood pressure levels between the groups. QRS, QT, QT_c, T_pT_e interval and T_pT_e/QT ratio were similar between the groups (p > 0.05). QTcd (65.7 ± 64.4 vs 42.1 ± 14.2 ms, p = 0.003) and T_pT_e dispersion (40.5 ± 14.8 vs 33.2 ± 4.9 ms, p = 0.006) were significantly longer in group 1 than group 2. COHb level was moderately correlated with TpTe dispersion (r = 0.29; p = 0.01).

Conclusion

To our knowledge, this is the first study to investigate T_pT_e interval and dispersion in CO poisoning. Our results showed that T_pT_e dispersion and QTc dispersion increased after CO poisoning.

Hypercholesterolemia is Accounted for Atherosclerosis at the Proximal Arterial Segments of Myocardial Bridging

Arterial shear stress was generally implicated in the development of atherosclerotic plaque (AP). Atherosclerotic plaque may be associated with myocardial bridging (MB). We evaluated the metabolic abnormalities which could determine the localization of AP at the proximal coronary segment of MB. We analyzed the patients with MB, AP&MB, and AP on left anterior descending (LAD) artery who were diagnosed by multislice computed tomography coronary angiography. Serum levels of metabolic parameters were compared among study groups. Patients with MB&AP and AP were significantly older than those in the MB group. Patients with MB&AP had AP and MB at the proximal and middle segments of LAD artery, respectively. Total cholesterol, low-density lipoprotein (LDL) cholesterol and very LDL, and triglyceride levels were significantly higher in patients with MB&AP and AP compared to only MB. Low-density lipoprotein cholesterol was significantly correlated with the type of coronary artery disease in multiple regression analysis. Myocardial bridging may be an anatomical determinant for the localization of AP proximal to itself in the presence of hypercholesterolemia.

Increased frequency of mitral valve prolapse in patients with deviated nasal septum

Any abnormality of collagen may affect the tissues with higher collagen content, e.g., joints, heart valves, and great arteries. Mitral valve prolapse (MVP) is a characteristic of generalized collagen abnormality. Nasal septum (NS) is constituted by osseous and cartilaginous septums that are highly rich in collagen. We evaluated the co-existence of deviation of NS (DNS) in patients with MVP. We retrospectively evaluated the recordings of echocardiographic and nasal examinations of subjects with MVP and DNS. We analyzed the features of MVP and anatomical classification of DNS among subjects. Totally, 74 patients with DNS and 38 subjects with normal nasal passage were enrolled to the study. Presence of MVP was significantly higher in patients with DNS compared to normal subjects (63 vs 26%, p < 0.001). Prolapse of anterior, posterior and both leaflets was higher in patients with DNS. Thickness of anterior mitral leaflet was significantly increased in patients with DNS (3.57 ± 0.68 vs 4.59 ± 1.1 mm, p < 0.001) compared to normal subjects. Type I, II, and III, IV DNS were higher in frequency in patients with MVP while type V and VI were higher in normal subjects. DNS is highly co-existent with MVP and increased thickness of mitral anterior leaflet. Generalized abnormality of collagen which is the main component of mitral valves and nasal septum may be accounted for co-existence of MVP and DNS. Also co-existence of them may exaggerate the symptoms of patients with MVP due to limited airflow through the nasal passage.

The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation

OBJECTIVE

To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE).

MATERIALS AND METHODS

The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study.

RESULTS

A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF.

CONCLUSION

A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.