The anatomical relationship between the axillary artery and vein investigated by radial coronary angiography.

AIMS: To reduce the risk of inadvertent arterial puncture and bleeding, we aimed to define a safe puncture site by demonstrating the relation of the axillary artery and vein. METHODS: The anatomical course and relation as well as crossover sites of the axillary artery and vein, the presence of small arterial bridges over the axillary vein, and validation of commonly preferred axillary venous puncture sites were determined by simultaneous ipsilateral venography in patients (n  =  111; 80 men, age 60 ± 10 years) who underwent coronary angiography by radial artery access. RESULTS: The axillary vein was detected at the first costa-clavicular intersection in 62% and at the second anterior and third posterior costal intersection in 60% of the patients. Small arterial bridges over the axillary vein were observed in 77% of the patients and more frequently in females and body mass index ≥25 kg/m2 (P  =  0.034 and P  =  0.03, respectively). The axillary artery crossed the vein in 24% of the patients and almost always within the region close to the first costa-clavicular intersection site. CONCLUSION: Our study demonstrated a high crossover rate (24%) of axillary artery and vein and a high degree of variation in the course of axillary vein. Small arterial bridges over the axillary vein were observed in 77% of the patients.

Increase in QRS amplitudes is better than N-terminal pro-B-type natriuretic peptide to predict clinical improvement in decompensated heart failure.

BACKGROUND: We aimed to investigate the correlation between ECG QRS voltage changes, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and clinical improvement in decompensated heart failure (DHF). METHODS AND RESULTS: DHF patients (n=56) with a mean age of 67.5±12.6 years showed limb QRS amplitude increase and NT-proBNP level decrease with clinical improvement (p<0.001). Significant correlation was found between percent changes (Δ%) in body weight and Δ% in QRS voltages of aVR, aVF, DII, ΣQRSI+II and ΣQRS (all limb-leads) (r = -0.40; r = -0.35; r = -0.32; r = -0.30; r = -0.30 respectively, p<0.05). No correlation was found between Δ% in NT-proBNP and body weight (r = -0.23, p=0.09). Δ% NT-proBNP was correlated with Δ% QRS voltage only in aVR (r = -0.312, p=0.019). In ROC analysis, ≥0.5 mm increase in aVR QRS voltage was found to predict ≥5 kg weight loss with a sensitivity of 74% and specificity of 62% (p=0.013, AUC: 0.699). CONCLUSIONS: Increase in QRS voltages especially in aVR was found to be more sensitive than NT-proBNP to predict clinical improvement in DHF.

Prevalence of Brugada-type electrocardiogram pattern by recording right precordial leads at higher intercostal spaces.

AIMS: Recording electrocardiograms (ECGs) by placing the right precordial leads at higher intercostal spaces (ICSs) increases the sensitivity for detecting Brugada-type ECG pattern (BTEP). Published studies unfortunately used standard lead positions for recording ECGs and underestimated the true prevalence of BTEP. Therefore, by placing right precordial leads at higher ICS, we aimed to find out the true prevalence of BTEP in our population. METHODS AND RESULTS: Healthy male volunteers (n= 504) between 18 and 55 years of age (37.3 ± 10.7 years) without known cardiac or metabolic disorders were enrolled into the study. After the standard ECG recording, two other recordings were obtained by placing the right precordial leads to the third and second ICS. Electrocardiograms were stratified by two independent reviewers for the presence of BTEP. There were 15 subjects (3%) who displayed BTEP on their standard ECG recordings. Number of cases displaying BTEP increased to 25 (5%) and 38 (7.5%) when the right precordial leads were moved to third and second ICS, respectively. Although none of the subjects displayed type 1 BTEP on their standard ECGs, three subjects displayed type 1 BTEP on the third and four subjects displayed type 1 BTEP on the second ICS. CONCLUSIONS: Our study revealed that the prevalence of BTEP in healthy male subjects was 7.5% by placing the right precordial leads to higher ICS. Instead of standard lead locations that are not sensitive enough for detection of BTEP we recommend high right ICS recording in further prevalence studies.

Subcutaneous placement of a free jejunum and pedicled colon segment to create a diversionary conduit for total esophageal reconstruction.

In this report, we describe a case of difficult esophageal reconstruction with a pedicled colon segment interposition and a free jejunal flap. Laryngectomy and bilateral neck dissection for larynx carcinoma had been attempted in a 59-year-old patient 6 years previously. The patient then received radiotherapy. One year later, large resection was performed due to recurrence of the tumor. Since then the patient had been fed through a gastrostomy tube. Previous attempts at esophageal reconstruction in other institutions were unsuccessful. We reconstructed the total esophagus with subcutaneously tunneled pedicled colon segment interposition and a free jejunal flap using the diversionary loop technique to divert the passage of the foot from the pharynx to the new inlet at the buccogingival sulcus, thus keeping the native esophagus untouched. Following a postoperative training period, the patient learned to swallow successfully and smoothly via the new inlet. The patency of the newly reconstructed esophagus was corroborated by radiological imaging. In summary, although the technique requires complex surgical procedures, it is effective and may be considered as an alternative and reliable option in selected cases.

Diagnostic utility of specific electrocardiographical parameters in predicting left ventricular function.

BACKGROUND: Changes in electrocardiography (ECG) parameters, including sinus tachycardia, atrial fibrillation, bundle branch blocks, Q waves and left ventricular (LV) hypertrophy, are commonly observed in patients with heart failure (HF). OBJECTIVES: To determine whether specific ECG parameters have a diagnostic role in predicting LV systolic dysfunction (LVSD) in patients with suspected HF. METHODS: A total of 123 patients with symptoms or signs of HF and 20 HF patients with New York Heart Association class IV status were consecutively recruited. Several ECG parameters, including QRS duration, dispersion and SV1 or SV2 + RV5 or RV6 ≥3.5 mV (Goldberger's first criterion), QRS amplitude ≤0.8 mV in the limb leads (Goldberger's second criterion) and RV4/SV4 <1 (Goldberger's third criterion), were subsequently determined and correlated with LV ejection fraction (LVEF). RESULTS: One hundred six patients had LVEF <50% (LVSD group), while 37 patients had LVEF ≥50% (non-LVSD group). The maximal QRS duration of the LVSD group was significantly longer than that of the non-LVSD group (124.5±20.8 ms versus 109.7±13.1 ms; P<0.001). ROC analysis revealed that a cut-off point of QRS duration ≥124 ms significantly predicted LVSD (OR 4.1 [95% CI 1.7 to 10.2]; P=0.001). The frequencies of Goldberger's first and third criteria were higher in the LVSD group (OR 8.3 [95% CI 1.9 to 36.4]; P=0.001; and OR 8.9 [95% CI 3.4 to 23.2]; P<0.001, respectively). Logistic regression analysis showed that Goldberger's first and third criteria as well as QRS duration ≥124 ms were independent predictors of LVSD. CONCLUSION: Bedside ECG parameters, such as the Goldberger criteria, may be useful in predicting LVSD before the use of more sophisticated diagnostic tests is considered in patients with suspected HF.

The prevalence of early repolarization variant in Turkish male subjects: a clinical single center study.

OBJECTIVES: Early repolarization variant (ERV) detected in surface ECG has traditionally been considered a benign finding, but the presence of this pattern has recently been associated with vulnerability to ventricular fibrillation in many case reports and case-control studies. There is no information regarding the prevalence of ERV within the Turkish population. The aim of this study was to evaluate the prevalence of ERV within a sample group of the healthy Turkish male population. STUDY DESIGN: We assessed the prevalence of ERV within a community-based general population of 504 healthy male subjects (mean age 37.3±10.7 years; range 18 to 55 years) using 12-lead electrocardiography. ERV was stratified by two independent cardiologists according to the J-point elevation (≥0.1 mV) in the inferior, lateral or both leads with QRS slurring or notching. RESULTS: The ERV pattern was present in 34 subjects (6.7%): 19 subjects (3.8%) displayed ERV in the lateral leads, 7 (1.4%) in the inferior leads, and 8 (1.6%) in both the lateral and inferior leads. CONCLUSION: The prevalence of ERV within the healthy Turkish male population seems to be similar to the findings of previous population-based studies.

Role of Serial Transverse Enteroplasty in the Management of Adult-Type Short Bowel Syndrome: Experience from a Single Tertiary Referral Hospital in Turkey.

BACKGROUND: There is little knowledge with regard to the management of intestinal failure in countries where home care services and dedicated intestinal rehabilitation centers are limited. This study presents a single-center experience of treating adult-type short bowel syndrome (SBS) with serial transverse enteroplasty (STEP). METHODS: Medical records were retrospectively reviewed from November 2009 to April 2018 on patients with adult-type SBS. All patients underwent STEP, and a representative quota sample of control patients treated with conventional measures were included. Clinico-demographic characteristics including baseline and post-treatment information about the orientation of bowel alignment and nutritional status were evaluated. RESULTS: The mean patient age was 51.1 ± 16.2 in the STEP group and 57.6 ± 12.7 in the control group (P = .304). The median small bowel length was 60 cm (interquartile range (IQR): 40-90) in the STEP group (before the lengthening) and 90 cm (IQR: 70-100) in the control (at the initiation of intestinal rehabilitation) (P = .035). Durations of median follow-up were 18 months (IQR: 14-58) and 10 months (IQR: 3-14), respectively (P = .019). In the STEP group, the mean increase in bowel length after STEP was 37.3 ± 11.6 cm, and at their follow-up 7 patients (64%) had successfully progressed to enteral autonomy. In the control group, only 3 patients (27%) were successful. Mean time to wean parenteral nutrition was 45 ± 54 days, and the mean increase in enteral calorie intake was 1.79 ± 1.60-fold after lengthening in the STEP group. CONCLUSIONS: STEP is an easy-to-perform procedure in the surgical rehabilitation of adult-type SBS. When performed simultaneously with reconnection surgery, it may offer a cost-effective and comprehensive solution to the treatment strategy in middle income settings.

Right ventricular outflow tract pacing: an alternative, safe, and effective pacing site.

The right ventricular apex (RVA) has traditionally been preferred for the insertion of permanent cardiac pacemaker leads because of vast experience with their use, their ease of implantation, and the stability of passive fixation leads in the RVA trabeculae. However, prolonged RVA pacing is associated with progressive left ventricular dysfunction due to dysynchronous ventricular activation, and often results in substantial functional, hemodynamic, electrical, and structural changes, as previously demonstrated in many studies. Only in recent years has interest in the use of alternate pacing sites developed. The right ventricular outflow tract (RVOT) is now the preferred site of pacing because of potential advantages such as ease of application, better hemodynamics, synchronous activation, fewer myocardial perfusion defects, and a narrower QRS complex compared with RVA pacing. This review article comprehensively discusses this novel technique in terms of its beneficial effects, long-term safety, and performance measures compared with RVA pacing, and as an alternative method for biventricular pacing.

Fever-induced precordial ST-segment elevation in a young man.

Brugada syndrome is a rare condition characterized by ST-segment elevation in the right precordial leads. Fever can induce Brugada-like electrocardiographic (ECG) changes. We reported on a 26-year-old male patient with fever and ST-segment elevation in the right precordial leads. Serial cardiac markers were normal and transthoracic echocardiography showed normal wall motion and no evidence for pericardial effusion. Brugada-like ECG changes disappeared after fever resolved. Since the patient had never experienced any arrhythmic symptom, syncope, or spontaneous type 1 ECG, electrophysiological study was not performed and he was not referred for defibrillator implantation. The patient was discharged with strong recommendations to avoid certain medications responsible for Brugada-like ECG changes and to receive urgent treatment for fever. He was asymptomatic during a year follow-up. Emphasis is placed on this particularly rare, but important condition, as it may easily be misdiagnosed and fever may even precipitate ventricular fibrillation.

The effect of global longitudinal strain on impaired six-minute walk test performance in patients with sarcoidosis.

BACKGROUND: Sarcoidosis is a multisystem and granulomatous disease associated with impaired functional capacity as a result of pulmonary and cardiac involvement. Factors adversely effecting functional capacity in patients with sarcoidosis have not been systematically assessed including myocardial strain imaging on echocardiography which enable to diagnose subclinical cardiac dysfunction. We aimed to evaluate the effect of left and right ventricular global longitudinal strain (GLS) on submaximal exercise capacity in patients with sarcoidosis who do not have clinically manifest cardiac involvement. METHODS: Extracardiac biopsy proven 56 patients with sarcoidosis and 26 controls were included consecutively. Submaximal exercise capacity of the subjects was assessed with six-minute walk test (6 MWT). Pulmonary function tests and standard transthoracic and two-dimensional speckle tracking echocardiography were performed to the all subjects. Linear regression analysis was performed to find independent predictors of 6 MWT. RESULTS: Fifty-six patients (18% male) with a mean age of 52.5 ± 10.7 years were included. Patients with sarcoidosis had low 6 MWT performance and higher New York Heart Association classes and NT-proBNP levels. There were no significant differences between controls and patients with sarcoidosis in parameters of pulmonary function test. Biventricular GLS levels and biatrial reservoir and conduit function values were lower and systolic pulmonary artery pressure (SPAP) was significantly higher in patients with sarcoidosis as compared with controls. Older age and higher SPAP were found as independent predictors of poor 6 MWT performance. CONCLUSION: Although biventricular GLS levels were lower in the patients with sarcoidosis, only age and SPAP elevations were independent predictors of the submaximal exercise capacity. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 63-73).

Diagnostic value of plasma fibronectin level in predicting the presence and severity of coronary artery disease.

The relation between fibronectin and coronary artery disease (CAD) according to previous study results is controversial. The aim of the present study is to investigate the predictive value of fibronectin in determining the presence and severity of CAD. Patients with stable angina (n=62) who had angiographically documented CAD, and control patients (n=31) who had normal coronary angiograms, were included in the study. Plasma fibronectin levels were determined in all patients. Plasma fibronectin level (milligrams per liter) in patients with CAD was higher than normal controls (364.2+/-171 vs 265.1+/-135.5, p=0.006). The severity of CAD determined according to Gensini score and fibronectin level did not show any correlation (r=0.13, p=0.311). If fibronectin level 240 mg/l was determined as cutoff, it showed 76% sensitivity, 46% specificity, 46% negative predictive value, and 72.3% positive predictive value for predicting CAD. The present study showed that plasma fibronectin level in CAD is significantly higher than normal control subjects. However, it has no role in predicting the severity of CAD.

Oral verapamil effectively suppressed complex ventricular arrhythmias and unmasked U waves in a patient with Andersen-Tawil syndrome.

Andersen-Tawil syndrome (ATS) is a rare, heterogeneous, autosomal dominant, or sporadic disorder characterized by the clinical triad of periodic paralysis, dysmorphic features, and ventricular arrhythmias such as bidirectional ventricular tachycardia (BVT). We present a case of an elderly patient with ATS whose symptomatic ventricular arrhythmias including BVT were effectively suppressed by oral verapamil therapy.

Intercostal muscle twitching: an unusual manifestation of extracardiac stimulation related to right ventricular outflow tract pacing.

The present case report describes a patient who underwent successful dual-chamber pacemaker implantation with active ventricular lead fixation at a high septal region in the right ventricular outflow tract. Unexpectedly, stimulation at a high output in the right ventricular outflow tract caused an unusual extracardiac stimulation, specifically, intercostal muscle twitching.

Horseshoe kidney for transplant: report of 3 cases.

Owing to the limited donor pool at transplant centers, grafts may be taken from marginal donors with congenital abnormalities, one of the most common of which is a fusion abnormality. Horseshoe kidneys may be transplanted to a single recipient en bloc or to 2 recipients after division. In our clinic, 3 grafts (1 obtained from a living donor and 2 from a deceased donor) were successfully transplanted to 3 patients. In select patients, horseshoe kidneys may be used for transplant.

Holter monitoring in the prognosis of sudden cardiac death.

The frequency and rate of either premature ventricular complexes or nonsustained ventricular tachycardia episodes as well as any transient conduction disturbance in a given patient with high risk features for sudden cardiac death (SCD) can be established with Holter monitoring and risk for future cardiac arrhythmic events predicted with reasonable probability. With the aid of published medical literature the present article discussed the role of nonsustained ventricular tachycardia and frequent premature ventricular complexes recorded with long-term Holter electrocardiography in predicting SCD associated with common cardiac disorders such as coronary heart disease, dilated and hypertrophic cardiomyopathy.

[Alternative site of ventricular pacing: right ventricular outflow tract]. / Kalici kalp pili uygulamasinda alternatif uyarilma yeri: Sag ventrikül çikis yolu.

The main reasons for traditional right ventricle apical pacing were first, the ease of implantation and second, the stability of passive-fixation leads in the apical trabeculae. However, apart from some specific diseases like hypertrophic cardiomyopathy, apical pacing often results in substantial functional, hemodynamic, electrical, and structural changes as previously demonstrated in many studies. Only in recent years, interest in the use of alternate pacing sites has developed. Right ventricular outflow tract is the preferred site of pacing because of its potential advantages such as ease of application, better hemodynamics, synchronous activation, less myocardial perfusion defects than apical pacing. The present review article comprehensively discusses this novel technique in terms of its beneficial effects compared to apical pacing and as an alternative method for biventricular pacing.

Right bundle branch block pattern during right ventricular permanent pacing: Is it safe or not?

The present case report describes a patient with dual chamber pacemaker whose surface ECG demonstrated paced right bundle branch block pattern suggesting a malpositioned ventricular lead in the left ventricle. However, diagnostic work-up revealed that the lead was appropriately located in the right ventricular apex. Diagnostic maneuvers and clues for differentiating safe right bundle branch block pattern during permanent pacing are thoroughly revisited and discussed within the article.