An unusual microorganism, Aerococcus viridans, causing endocarditis and aortic valvular obstruction due to a huge vegetation.

Aerococcus viridans is not a common pathogen, and endocarditis due to A. viridans is very rare. A 44-year-old woman with persistent atrial fibrillation and rheumatic valvular heart disease was admitted with fever, sweating, weakness, and progressive shortness of breath. Transthoracic echocardiography (TTE) demonstrated a 8x9-mm vegetation attached to the right coronary cusp of the aortic valve, causing aortic obstruction. Blood cultures yielded A. viridans susceptible to penicillin. Despite optimal antibiotherapy, subsequent TTE controls revealed enlargement of the vegetation, reaching a size of 21x10 mm, and an increasing gradient across the aortic valve. The patient underwent successful aortic and mitral valve replacement and was stable in the postoperative period without any problem. This represents the first reported case of A. viridans endocarditis in which the size and location of vegetation caused obstruction to blood flow, indicating surgery.

Plasma homocysteine level and left ventricular thrombus formation in acute anterior myocardial infarction patients following thrombolytic therapy with t-PA.

AIMS: The aim of this study was to evaluate the relationship between homocysteine levels and the development of left ventricular thrombus in acute anterior myocardial infarction patients directed to thrombolytic therapy. METHODS AND RESULTS: Seventy-nine patients presenting with ST elevated acute anterior myocardial infarction and treated with thrombolytic agent, t-PA, were included in the study. Two-dimensional echocardiography was used to divide patients into 2 groups according to the presence (n = 14) or absence (n = 65) of thrombus in the left ventricle following myocardial infarction. The levels of fasting plasma total homocysteine, total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, vitamin B12 and folic acid were assessed. There were no significant differences between two groups in terms of age, gender, hyperlipidemia and smoking. History of diabetes mellitus (28.57% versus 6.15%, p = 0.04), peak creatine phosphokinase levels (4153.54 +/- 1228.41 U/L versus 2456.92 +/- 1421.36 U/L, p < 0.001), mean left ventricular wall motion score index (2.21 +/- 0.18 versus 1.83 +/- 0.23, p < 0.001) and total fasting homocysteine levels (18.24 +/- 5.67 mmol/L versus 12.31 +/- 3.52 mmol/L, p < 0.001) were significantly higher in patients with left ventricular thrombus. In multivariate analysis; only diabetes mellitus (p = 0.03), higher wall motion score index (p = 0.001) and higher homocysteine levels (p = 0.04) were independent predictors of left ventricular thrombus formation. CONCLUSION: Our results suggest that; diabetes mellitus, higher wall motion score index and hyperhomocysteinemia independently increases the risk for the development of left ventricular thrombus formation in patients with acute anterior myocardial infarction following thrombolytic therapy.

The relation between insulin resistance determined by homeostatic [corrected from haemostatic] modelling and slow coronary flow.

INTRODUCTION: In this study, we sought to determine whether insulin resistance, which is investigated by homeostatic modelling, is related to slow coronary flow (SCF). MATERIALS AND METHODS: A total of 24 patients with SCF (4 females/20 males, mean age 47 +/- 12 years) and 32 patients with normal coronary artery (10 females/22 males, mean age 52 +/- 12 years) were included in the study. Baseline glucose, insulin and plasma lipid levels were measured. A standard oral glucose tolerance test (OGTT) was performed and post-challenge insulin levels were also measured. The index of insulin resistance was calculated with the homeostatic modelling [homeostatic model assessment for insulin resistance index (HOMA-IR)]. RESULTS: There were no differences between the 2 groups with regard to age, lipid levels, blood pressure levels, history of smoking, fasting and post-challenge plasma glucose. Baseline insulin levels were augmented in the SCF group (9.64 +/- 5.93 vs 7.04 +/- 3.26, P = 0.041). HOMA-IR levels were not different between the study groups (2.20 +/- 1.44 vs 1.69 +/- 0.86, P = 0.129). Manifest insulin resistance was significantly higher in the CSF group as compared with the control group (25% vs 3%, P = 0.01). CONCLUSION: Manifest insulin resistance is seen more frequently in patients with SCF.

Predicting breast attenuation in patients undergoing myocardial perfusion scintigraphy: a digital x-ray study.

Attenuation artifacts are the most common sources of error in myocardial single-photon emission computed tomography (SPECT) imaging. Breast artifacts are the most frequent causes of false positive planar images in female subjects. The purpose of this study was to predict breast adverse attenuation by measuring breast tissue thickness with digital x-ray. Sixty-five consecutive female patients with angina pectoris, who were referred to myocardial perfusion scintigraphy were enrolled in this study. Eighteen patients with normal perfusion imaging and normal coronary angiography composed the first group, whereas the second group consisted of 28 patients with a positive exercise electrocardiogram with anterior ischemia on myocardial perfusion imaging and greater than 50% left anterior descending artery stenosis on angiography. Nineteen patients in the third group had normal exercise electrocardiograms and normal coronary angiographies, but anterior ischemia on perfusion imaging. Digital x-ray records were obtained for measuring breast tissue thickness and Hounsfield density. The rate of breast adverse attenuation was 40% (19/47) in patients with anterior ischemia. The sensitivity and specificity of the prediction of breast adverse attenuation (lateral density less than 550 Hounsfield) were 79% and 11%, respectively. When breast attenuation for a breast thickness greater than 6 cm measured in the left anterior oblique view was predicted, the sensitivity and specificity were 79% and 93%, respectively. In conclusion, breast thickness greater than 6 cm measured from the left anterior oblique view with digital x-ray can predict breast adverse attenuation in female patients, and thereby may decrease the number of unnecessary invasive diagnostic procedures to be performed.

Preoperative clinical status but not waiting time predicts in-hospital outcomes of surgery in patients with left main coronary artery stenosis.

Contoversy exists about the optimal operation time of the patients with left main coronary artery (LMCA) stenosis. We therefore, aimed to investigate the effect of waiting time on in-hospital morbidity and mortality in patients with LMCA stenosis and identify the risk factors associated with adverse cardiovascular events before and during surgery. One hundred seventy six patients with LMCA stenosis were divided into two groups according to the time period between coronary angiography and coronary artery bypass surgery (group 1: 7 days, 82 patients). Primary end points were death and major adverse cardiac event (MACE): in-hospital death, sustained ventricular tachycardia or ventricular fibrillation development, postoperative stay in the intensive care > 48 hrs and in hospital > 9 days. Demographic and clinical characteristics of patients in groups 1 and 2 were comparable. There was no difference between the two groups in terms of in-hospital morbidity, mortality and MACE. When we analyzed the differences between the patients with and without MACE, the patients who experienced MACE were older (p = 0.001), and had higher degree of LMCA stenosis (p = 0.01), higher degree of right coronary artery stenosis (p = 0.02), higher blood urea level (p = 0.003), and higher incidence of unstable angina or myocardial infarction within 2 weeks (p = 0.001). Independent risk factors for MACE were unstable angina or myocardial infarction within 2 weeks, age more than 70 years and stenosis more than 75% in the LMCA. These results suggest that preoperative clinical status but not waiting time predicts in-hospital surgical outcomes in LMCA stenosis.

Effects of folic acid and N-acetylcysteine on plasma homocysteine levels and endothelial function in patients with coronary artery disease.

OBJECTIVE: Hyperhomocysteinaemia is related with premature coronary artery disease and adverse cardiac events in patients with coronary artery disease (CAD). It is assumed that hyper-homocysteinaemia causes endothelial dysfunction. In this study, the effect of folic acid and oral N-acetylcysteine (NAC) therapies on plasma homocysteine levels and endothelial function were evaluated in hyperhomocysteinaemic patients with CAD. METHODS AND RESULTS: 60 patients were randomized to either folic acid 5 mg or NAC 600 mg or placebo daily for eight weeks. Brachial artery endothelial functions were studied by using high-resolution ultrasound and assessed by measuring endothelium-dependent dilation (EDD) and endothelium-independent dilation (NEDD). Folic acid and NAC therapies decreased plasma homocysteine (from 21.7 +/- 8.7 micromol/l to 12.5 +/- 2.5 micromol/l, P < 0.001; from 20.9 +/- 7.6 micromol/l to 15.6 +/- 4.3 micromol/l, P = 0.03, respectively), and increased EDD (6.7 +/- 6.1% P = 0.002, 4.4 +/- 2.6% P < 0.001, respectively) compared with placebo. There was no significant difference in improving EDD between the folic acid and the NAC group (6.7 +/- 6.1%, 4.4 +/- 2.6%, P = 0. 168). In the univariate analyses there was an inverse correlation between the post-treatment homocysteine level and the percent change in EDD with folic acid therapy (r= -0.490, P = 0.028), but there was no correlation with the NAC therapy (r = 0.259, P = 0.333) CONCLUSION: In patients with hyperhomocysteinaemic CAD, folic acid and NAC lowered plasma homocysteine levels and improved endothelial function. The effects of both treatments in improvement of EDD were similar.

Left main coronary thrombosis with essential thrombocythemia.

Essential thrombocythemia is a disorder that causes persistent increase in the platelet count. The disease is associated with an elevated risk of thrombosis. A 71-year-old woman was diagnosed with left main coronary thrombosis after an angiogram due to stable angina. One week before the angiogram was taken the patient had also been diagnosed with essential thrombocythemia. After appropriate medical treatment for 5 days the patient underwent an excimer laser treatment, which failed in dissolving the thrombus. Before the patient underwent coronary surgery, thrombopheresis was performed in order to reduce the platelet count. After a successful coronary operation the patient improved completely.

Right atrial mass presenting as cardiac tamponade.

Intracavitary tumors such as angiosarcomas are prone to embolize, and occlude valves and vessels. Intramyocardial tumors cause cardiac failure and arrhythmias. Pericardial tumors cause effusions which result in tamponade. It is very rare that an intracavitary tumor presents itself with a cardiac tamponade. A 32-year old woman presented to the emergency room with palpitation and shortness of breath. Her physical examination revealed pulsus paradoxus and jugular venous distention. The transthoracic echocardiography showed normal left ventricular function, and an intracavitary right atrial mass. As the patients clinical status deteriorated an emergency operation was performed. The hemorrhagic pericardial fluid was cytologically positive for malignant cells. Histopathological findings were indicative of an angiosarcoma.

Hydatid disease involving the left ventricle: a case of unusual combination.

Hydatid cyst can be found in many organ systems, but is rarely in the heart. Echocardiography is an important tool in diagnosing cardiac involvement of a hydatid cyst. A history of extracardiac hydatid cyst should raise suspicion whether there is cardiac involvement. We report a case of spinal hydatid cyst with left ventricular hydatid cyst, yet without any hepatic or pulmonary involvement.

An interatrial mass supplied from dual coronary circulation.

A 69-year-old woman has been complaining from presencop and palpitation for 4 months. Cardiac examination revealed middiastolic rulman, which changed by position. Transthoracic and transesophageal echocardiography showed normal left ventricular function, mild mitral regurgitation and large right and left atrial masses. This mass prolapsed through the mitral valve into the left ventricle during diastole and caused dynamic obstruction. Coronary angiography revealed that the masses were supplied via left and right coronary artery without any significant stenosis of the coronary arteries. Prediagnosed, however, as multiple myxomas, the results of the pathology indicated a completely different origin.

Effect of hormone replacement therapy on plasma lipoproteins and apolipoproteins, endothelial function and myocardial perfusion in postmenopausal women with estrogen receptor-alpha IVS1-397 C/C genotype and established coronary artery disease.

UNLABELLED: Effect of hormone replacement (HRT) therapy on plasma lipoproteins and apolipoproteins, endothelial function and myocardial perfusion in postmenopausal women with estrogen receptor-alpha (ER-alpha) IVS1-397 C/C genotype and established coronary artery disease. BACKGROUND/AIMS: Associations between various ER-alpha polymorphisms and clinical phenotypes have been studied, including lipid levels and coronary atherosclerosis. We studied 48 postmenopausal women to determine the effect of ER-alpha IVS1-397 polymorphism on the response to treatment with HRT. METHODS: The study had a randomized, double-blind, placebo-controlled and crossover design. Patients were divided into two groups according to ER-alpha IVS1-397 polymorphism: CC genotype (n = 9); CT or TT genotype (n = 39). HRT was given continuously for 4 weeks, with 4-week washout periods between the treatment periods. Brachial artery Doppler and Tl-201 scintigraphy were performed at the end of each treatment period. RESULTS: HRT lowered total cholesterol, LDL-c and Apo-B levels from baseline values (all p < 0.05) and to a similar degree in CC and CT/TT genotype patients. HRT increased estradiol, HDL-c and Apo A-1 levels relative to baseline values, but to a greater degree in CC patients (p = 0.04, 0.05 and 0.04 by ANOVA, respectively). HRT increased peak forearm blood flow, brachial artery diameter during reactive hyperemia and endothelium-dependent dilation in both groups, but to a greater degree in CC patients (p = 0.03, 0.03 and 0.04 by ANOVA, respectively). Summed stress and rest scores were also more markedly reduced in CC patients (p = 0.04 and 0.05, respectively). The increase in estradiol levels was strongly correlated with the improvement in endothelium-dependent dilation (r = 0.66, p < 0.01), which in turn showed negative correlation with summed stress (r = -0.62, p < 0.01) and rest scores (r = -0.52, p < 0.05) in the CC genotype group. CONCLUSION: These data suggest that the improvement in endothelium-dependent dilation and the reduction in perfusion abnormalities by increasing estradiol levels with HRT in postmenopausal women with coronary artery disease may differ with respect to different genotypes, the effect being more prominent in those patients with ER-alpha IVS1-397 CC genotype.

Heart rate variability in patients with systemic sarcoidosis.

PURPOSE: The identification of subjects with systemic sarcoidosis at higher risk for sudden death is an unresolved issue. An influence of the autonomic activity on the genesis of ventricular arrhythmias was postulated. Heart rate variability (HRV) analysis provides a useful method to measure autonomic activity, and is a predictor of increased risk of death in various conditions. Therefore, the aim of the study was to evaluate HRV in patients with systemic sarcoidosis. METHODS: The study included 35 patients with biopsy proven systemic sarcoidosis who were not taking antiarrhythmic medications. Thallium scintigraphy was performed to all patients with systemic sarcoidosis. The cardiac sarcoidosis was accepted in 16 patients as abnormal thallium scintigraphy and normal coronary arteriography. The time-domain analysis of HRV was expressed as the standard deviation of all normal to normal NN intervals (SDNN) detected during 24-hour Holter monitoring. Twenty-four healthy subjects represented a control group for HRV analysis. RESULTS: There were no differences in age (44 +/- 13 years for cardiac sarcoidosis, 42 +/- 15 years for noncardiac sarcoidosis, and 40 +/- 10 years for control group; P = NS), sex (the ratio of female; 63%, 68%, and 55%, respectively; P = NS), and echocardiographic ejection fraction (63 +/- 10%, 67 +/- 8%, and 69 +/- 6%, respectively; P = NS) among study groups. The mean SDNN value of the group with cardiac sarcoidosis was significantly lower than both the group with noncardiac sarcoidosis and the control group (72 +/- 32 ms vs 110 +/- 46 ms and 152 +/- 36 ms; P < 0.05, respectively). CONCLUSION: HRV is decreased in patients with systemic sarcoidosis compared to the control group. This decreasing is more obvious in patients with cardiac sarcoidosis.

Unusual presentation of a patient with arrhythmogenic right ventricular dysplasia treated with a Glenn shunt.

Clinically, arrhythmogenic right ventricular dysplasia (ARVD) usually presents with ventricular arrhythmias, and unusual presentations were reported as acute coronary syndrome, heart failure and electrical storm. Taking all this different presentations and treatments in to account, we report a case of ARVD presenting with central cyanosis and clubbing simulating congenital heart disease. Besides this unusual presentation, the patient underwent also an unusual operation for this kind of abnormality, which cured the cyanosis completely.