Coronary rupture and pseudoaneurysm formation after extravascular migration of a paclitaxel eluting stent implanted in the left circumflex coronary artery.

As the implantation of drug eluting stents (DES) has become one of the most common clinical practices in interventional cardiology, the complications secondary to this procedure appear to have emerged increasingly over the past decade, with many cases of development of new coronary artery true aneurysms after DES implantation being reported. Here we present a case of coil embolization of a coronary pseudoaneurysm which presumably formed after extravascular migration of a DES.

Torsade de pointes associated with moxifloxacin: a rare but potentially fatal adverse event.

Torsade de pointes occuring due to a long QT interval is a rare but potentially fatal arrhythmia. Acquired long QT develops most commonly because of drugs that prolong ventricular repolarization. It has been reported that fluoroquinolone antimicrobials prolong the corrected QT interval but rarely cause torsade de pointes. A patient with torsade de pointes risk factors (female sex, advanced age, extreme bradycardia and renal failure) who developed the condition on the fourth day of 400 mg/day of oral moxifloxacin treatment is presented. After the moxifloxacin was stopped, the corrected QT interval normalized and a permanent cardiac pacemaker was implanted. During 11 months of follow-up, arrhythmia did not recur.

Increased frequency of familial Mediterranean fever in Central Anatolia, Turkey.

OBJECTIVE: It has been observed that familial Mediterranean fever is more prevalent among people coming from central Anatolia in Turkey. To test this observation the frequency of FMF was investigated by afield survey in Sivas, a city located in central of Turkey. METHODS: The survey was conducted in a cohort of 4809 persons selected by systematic sampling from 2 districts of Sivas, with a total population of 83,274. Face to face interviewing was done with registered households using a standard questionnaire developed to screen FMF A second interview was conducted by a rheumatologist and an internist of those individuals who were regarded to have possible FMF. RESULTS: The suspicion of FMF emerged in the cases of 46 individuals during the survey and 36 were interviewed for a second time. FMF was diagnosed in 10 cases. Only one had a previous diagnosis of FMF. The overall frequency of FMF among a cohort of 3,948 inhabitants of Sivas was 1/395 (0.25%). CONCLUSION: This study indicates that the prevalence of FMF in Sivas may be higher than that in general Turkish population, which has been reported to be 0.1%.

Angiographic and clinical follow-up after coronary implantation of the ACS Multilink Duet stent: a single center experience.

As a growing variety of coronary stents become available on the market and the results of randomised trials may be difficult to apply to less selected patients, detailed information about the immediate and long term results achieved with one device can be helpful for the interventional cardiologist. The purpose of the present study was to test the applicability, angiographic and clinical results of the ACS Multilink Duet coronary stent in a relatively unselected group of patients undergoing coronary angioplasty immediately and in the long term. From November 1998 to May 2000, 337 ACS Multilink Duet coronary stents were implanted in 285 patients in our clinic. Data were collected retrospectively from the catheterization laboratory records and patient charts. Restenotic lesions and chronic total occlusion stenting were excluded from analysis (45 patients and 60 stents were excluded leaving 240 patients, 262 lesions and 277 stents for analysis). In 3 cases (1%) the ACS Multilink Duet stent did not cross the lesion and another device was used. One patient (0.4%) died due to acute occlusion of the proximal left anterior descending artery and cardiogenic shock within 4 hours after the procedure. Three patients (1.25%) had subacute thrombosis and q wave myocardial infarction during the hospital course, while four additional patients, out of 197, in whom one month clinical data were available had myocardial infarction (2 q waves and 2 non-q waves) after hospital discharge in the first month (2.03%). After 6 months from the procedure angiographic follow-up data were available for 108 patients (45%), 111 lesions (42.4%) and 117 stents (40.4%). They had complex lesions, B2-C type accounting for 42.3% of the cohort, and lesions requiring 2.5 mm diameter stents were also included and constituted 11.1% of the study cohort. Restenosis occurred in 24 patients (21.4%) and in 25 stents (22.2%). Comparing the patients with and without restenosis, diabetes mellitus and complex lesion morphology (B2-C) were found to be more frequent in the restenosis group (p<0.01, p<0.01). Lesions suitable to stent with a stent diameter of 3.5 mm or more had less restenosis with respect to smaller diameters (p=0.022). For a single stent diameter restenosis rates, regarding the stent length were 14.2% for 8 mm and 13 mm, 18.6% for 18 mm, and 37.5% for 23 mm and 28 mm (p=not significant). The Multilink Duet stent, in a cohort of relatively unselected patients, has a high rate of applicability, an acceptable rate of subacute occlusion, and a low rate of restenosis.

Predictive value of mitral annular calcification for the diagnosis of coronary artery disease in patients with dilated cardiomyopathy.

Mitral annulus calcification (MAC) is an independent predictor of coronary artery disease (CAD). The present study was designed to determine whether an association exists between MAC and CAD in patients with dilated cardiomyopathy. Among the 286 patients with MAC on echocardiographic examination who underwent coronary angiography, 55 patients with echocardiographic findings of dilated cardiomyopathy (group I) were compared to 60 age-matched controls without MAC and an echocardiographic diagnosis of dilated cardiomyopathy (group II) who underwent coronary angiography during the same time. There were no differences in echocardiographic findings between two groups. The prevalence of CAD was higher in group I when compared to group II (74% vs 28%, p<0.001). With regard to severity of CAD, two-vessel, three-vessel, and left main coronary artery disease were found to be significantly frequent in group I (p<0.001). Multivariate analysis revealed that MAC (p=0.001), diabetes mellitus (p=0.048), and history of anginal chest pain (p=0.009) are the independent predictors for the presence of CAD in patients with dilated cardiomyopathy. In conclusion, MAC may be a marker for the presence of coronary artery disease in patients with dilated cardiomyopathy.

The relation between transmitral early filling wave deceleration time and the recovery of atrial contractility after electrical cardioversion of atrial fibrillation.

BACKGROUND: Electrical cardioversion of atrial fibrillation (AF) to sinus rhythm is associated with transient left atrial dysfunction and this phenomenon may lead to thrombus formation and embolic stroke. Delay of atrial mechanical function recovery may be related to ventricular diastolic function. OBJECTIVE: This study examined the effects of left ventricular diastolic function as well as the multiple clinical factors on the recovery of atrial systolic function after cardioversion for atrial fibrillation. METHODS: A total of 44 patients (28 male, 16 female, 61+/-18 years) with chronic AF (> or =1 month) underwent electrical cardioversion. Deceleration time of early filling wave (pre-CV EDT) on transmitral inflow obtained by using Doppler echocardiography before cardioversion and serial transmitral inflow Doppler variables were recorded through a 1 week study period in all patients. Various clinical (age, gender, the duration of AF) and echocardiographic variables (pre-CV EDT, left atrial dimension, left ventricular ejection fraction) were tested for an association with peak atrial filling wave velocity (VA) on day 1, 3 and 7 after cardioversion. RESULTS: EDT measured before cardioversion had a strong linear correlation with peak VA on every echocardiographic evaluation after cardioversion (Regression coefficient (R)=0.69, P<0.001; R=0.78, P<0.001 and R=0.83, P<0.001, on day 1, day 3 and day 7, respectively). The effect of left ventricular ejection fraction on peak VA was weaker than those of EDT. The duration of AF showed an inverse association with the recovery of atrial function, but this lost on multivariate analysis. None of the other parameters significantly correlated with peak VA after cardioversion. CONCLUSION: The recovery of atrial mechanical function after cardioversion, as assessed by peak VA on transthoracic Doppler echocardiography is mainly associated with the left ventricular diastolic function as measured by EDT, whereas the left ventricular systolic function relatively a small effect on this outcome. The duration of AF does not have any association with peak VA, possibly if it is chronic.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease.

BACKGROUND: Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. OBJECTIVE: We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. METHODS: Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. RESULTS: Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease. CONCLUSION: Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Hyperhomocysteinemia and restenosis.

OBJECTIVE: This study was undertaken to assess the effect of plasma homocysteine level on angiographic restenosis 6 months after coronary angioplasty. METHODS: The plasma homocysteine level was measured in 100 consecutive patients at the time of coronary angioplasty, 56 patients who attended a 6-month follow-up angiogram being enrolled to the study; the 44 patients without a control coronary angiogram were not enrolled. Patients with and without angiographic restenosis were designated as groups A (n = 34) and B (n = 22) respectively. RESULTS: The baseline demographic (groups A and B), angiographic (groups A and B) and procedural characteristics were similar in both groups. The mean plasma homocysteine level (SD) was 15.2 (7.7) and 11.1 (2.5) mumol/l in groups A and B respectively (P = 0.007; 95% CI -6.9 to -1.1). With respect to the plasma homocysteine level, the upper and the lower thirds were compared by binary logistic regression (the lower third homocysteine level being < 10.6 mumol/l and the upper third homocysteine level > 14.1 mumol/l). The angiographic restenosis rate for the lower and upper tertiles was 47.4% and 89.5% respectively (P = 0.01; OR = 9.4; 95% CI 1.6-52.7). After adjustment for age and sex, the statistical significance did not change (P = 0.013; OR = 9.43; 95% CI 1.6-54.9). Even after adjustment for age, sex, smoking, hypertension, hypercholesterolemia, and diabetes mellitus, there was a statistically significant difference between the upper and lower tertiles (P = 0.008; OR = 41.3; 95% CI 2.6-635). CONCLUSION: Increased plasma homocysteine level and diabetes mellitus were independent risk factors for angiographic restenosis after percutaneous transluminal coronary angioplasty and coronary stenting.

Lengthening of intraatrial conduction time in atrial fibrillation and its relation with early recurrence of atrial fibrillation.

Intraatrial conduction delay in atrial fibrillation (AF) that is considered a component of atrial electrical remodeling has been demonstrated previously in experimental models and it is considered an important factor for the induction or stabilization of AF. However, it is not known if this phenomenon exists in human AF. The present study aimed to compare intraatrial conduction time (IACT) in patients with chronic atrial fibrillation who were converted to sinus rhythm and a matched control group, and to investigate its relation with early AF recurrence. Seventeen patients with chronic AF (mean duration of 20.71+/-16.35 months) were enrolled in the study (7 males, 10 females, 63+/-8 years). An age and sex matched control group (n=12) consisted of patients with sinus rhythm who underwent electrophysiological study (EPS). None of the patients were on any antiarrhythmic treatment during the procedures. Cardioversion was performed via external DC cardioversion. Eight patients in the control group were delivered a DC shock because of induced ventricular tachycardia during EPS. IACT was defined as the interval between the onset of P wave surface ECG and the beginning of A wave at high right atrium (IACT 1) and low right atrium (IACT 2). Additionally, the interval between A wave at high right atrium and low right atrium was measured (IACT 3). Patient characteristics such as age, sex and echocardiographic variables were not different between the AF group and the control group. Heart rate after cardioversion was found to be similar between the two groups. Total delivered energy was significantly higher in the AF group than in the control group (464.47+/-165.82 joules vs. 315.00+/-27.77 joules, p<0.001). IACT 1 (15.30+/-7.61 msec vs 8.50+/-5.29 msec, p<0.02 ), IACT 2 (45.25+/-836 msec vs 26.44+/-10.45 msec, p<0.001) and IACT 3 (26.9+/-8.26 msec vs. 18.67+/-10.05, p<0.05) significantly lengthened in the AF group after maintenance of sinus rhythm compared to the control group. There were 6 early AF recurrences during the 1 week follow-up period. Multivariate analysis, revealed IACT 2 and IACT 3 were significantly different between the control group, the patient with recurred AF and the patients with maintained sinus rhythm. Post-hoc analysis revealed that IACT 2 and IACT 3 significantly lengthened in the patients with recurred AF compared to both the control group and patients with maintained sinus rhythm. On the other hand, only IACT 2 patients with maintained sinus rhythm were found to be higher than those of the control group. The present study indicated that intraatrial conduction was disturbed in patients with AF, a finding which is consistent with those of previous experimental studies. Additionally, such a phenomenon may be a risk factor for the early recurrence of AF after cardioversion to sinus rhythm.

THE EFFECT OF BIOMASS FUEL COMBUSTION ON PULMONARY FUNCTION TESTS IN THE ADULT POPULATION OF SIVAS PROVINCE.

The effects of natural traditional energy sources which is called biomass, mainly cowdung, on pulmonary function was investigated. In rural regions of Sivas City, pulmonary function tests of 112 cow-dung users and 153 modern energy source users were compared. When comparing the mean values of spirometric measurements of two groups' males and females seperately, all the spirometric parameters of the cow-dung users' group were found to be decreased (P < 0.05) and this decrement was in obstructive type. As a result, cow-dung which is a special type of biomass, was seen to effect pulmonary function tests negatively both in males and females.