Simultaneous pacing from two branches of coronary sinus in a patient with prosthetic tricuspid valve and complete heart block.

BACKGROUND: Complete heart blocks underwent to permanent pacemaker placement are a common complication of tricuspid valve replacement (TVR). If indicated, endocardial placement of a right ventricular (RV) lead is precluded in the presence of mechanical TVR. CASE PRESENTATION: A 20-year-old female patient firstly underwent metallic prosthetic valve operation with tricuspid valve endocarditis in 2014. Three years after the operation, echocardiography revealed dysfunction of the prosthetic valve thus reoperation was decided. In the second operation, the patient underwent a bioprosthesis valve and AV complete block developed in the postoperative period. Left ventricular ejection fraction (EF) was 45% was found on echocardiography. Pacemaker dependence of the patient, it was aimed to place two electrodes into the left ventricle. Electrodes were placed the target two branches in coronary sinus (CS) and right atrium. Univentricular bifocal pacing was enabled to work. CONCLUSION: Electrode placement in the CS is a very good alternative to epicardial surgical lead placement in cases where endocardial lead placement from the right atrium to the RV is contraindicated. In patients with lower left ventricular EF who will be pacemaker dependent, the insertion of two electrodes into the CS to prevent pacemaker is a safe and effective treatment.

A Novel Marker of Inflammation: Azurocidin in Patients with ST Segment Elevation Myocardial Infarction.

(1) To investigate the role of azurocidin, an antimicrobial protein, in patients with ST segment elevation myocardial infarction (STEMI). (2) This single-center prospective observational study included patients with STEMI and healthy age- and sex-matched control subjects. Baseline demographic, clinical and biochemical data were compared between the two groups. Azurocidin levels at baseline were determined using an enzyme-linked immunosorbent assay. Multivariate linear regression analysis with enter method was used to test the association between azurocidin and independent variables, such as the thrombolysis in myocardial infarction (TIMI) score, synergy between percutaneous coronary intervention with TAXUS and cardiac surgery score, global registry of acute coronary events score, Killip class, C-reactive protein (CRP), and creatinine kinase-myocardial band (CK-MB). (3) A total of 76 patients with STEMI and 30 healthy control subjects were enrolled in the study. Mean ± SD azurocidin levels were significantly higher in patients compared with healthy controls (18.07 ± 13.99 versus 10.09 ± 5.29 ng/mL, respectively). In a receiver-operating characteristic curve analysis, an azurocidin cut-off level of >11.46 ng/mL had 74% sensitivity and 58% specificity in predicting myocardial infarction. Azurocidin levels had a positive correlation with TIMI score (r = 0.651). In multivariate linear regression analysis, the TIMI score was an independent predictor of the azurocidin level. (4) Azurocidin is an infection marker that may be important in patients with STEMI.

Blood flow restriction training on physical parameters in elite male canoe athletes.

BACKGROUND: To investigate the effect blood flow restriction (BFR) exercises on muscle size, strength and athletic performance in elite canoe athletes aged 18 to 25 years. METHODS: This was a randomized controlled trial. The participants were divided into 2 groups: the intervention group (INT-gr) (n = 17, age: 18.59 ± 0.71 years) and the control group (CONT-gr) (n = 16, age: 18.81 ± 1.11 years). Anthropometric measurements, muscle size measured by ultrasound (US), strength measurements with an isokinetic dynamometer, and ergometer performance with an indoor ergometer were conducted before and after the exercise program. Knee flexion and extension and leg press one-repetition maximum (1 RM) tests were performed to determine the participants' training program. The INT-gr performed 1 RM 30% resistance training + BFR for 8 weeks, while the CONT-gr performed 1 RM 30% resistance training (RT) without BFR with their routine training program. US was used to measure the cross sectional area (CSA) and thickness of the quadriceps femoris (QF) and Hamstring (H) muscles in the pre-post design, and the isokinetic dynamometer was used to measure the strength of bilateral 60˚/s and 300˚/s peak torque (PT) values of the QF and H. Sports performance was tested on an indoor ergometer at distances of 200, 500, and 1000 m. RESULTS: The changes in bilateral rectus femoris (RF) CSA and VL thickness measurements in the INT-gr were significant (P < .05). Ergometer performance measurements showed a significant improvement over CONT-gr at all distances (P < .05). In terms of strength scores measured by the isokinetic dynamometer, the right QF and H 300˚/s and the left QF 60˚/s PT values were significantly in favor of INT-gr. CONCLUSION: BFR exercises are effective to increase strength, muscle size, and ergometer performance in elite canoe athletes.

New indicator of cellular ischemia in coronary slow-flow phenomenon: Cell-free DNA.

OBJECTIVE: Coronary slow-flow phenomenon (CSFP) is defined as the delayed arrival of coronary blood flow to the distal vascular bed in at least 1 major epicardial coronary artery. Cell-free DNA (cfDNA) is a type of DNA that circulates freely in the blood once released from nucleated cells. The aim of this study was to determine if the level of cfDNA, which is an indicator of ischemia at the cellular level, was increased in CSFP. METHODS: The study included 46 patients in total: 23 patients with CSFP and 23 with a normal coronary angiogram (NCA). The level of cfDNA, and clinical, biochemical, and angiographic features of the groups were compared. RESULTS: The mean age was 53.8±10.3 years for the CSFP patient group and 56.6±9.4 years for the NCA patient group. There was no statistically significant difference between the groups in terms of basal clinical characteristics or laboratory data. The plasma cfDNA level was 5.04±2.37 ng/µL in the CSFP patients and 2.28±1.09 ng/µL in the NCA group (p<0.001). CONCLUSION: Several invasive and noninvasive studies conducted on patients with CSFP have revealed myocardial ischemia. The results of this study demonstrated that the level of cfDNA was significantly increased in patients with CSFP as a result of ischemia at the cellular level caused by microvascular disruption.

Coronavirus disease 2019 (COVID-19) and simultaneous acute anteroseptal and inferior ST-segment elevation myocardial infarction.

Coronavirus disease 2019 (COVID-19) is a recently recognised pandemic spreading rapidly from Wuhan, Hubei, to other provinces in China and to many countries around the world. The number of COVID-19-related deaths is steadily increasing. Acute ST-segment elevation myocardial infarction (STEMI) is a disease with high morbidity and mortality rates, and primary percutaneous coronary intervention is usually recommended for the treatment. A patient with diabetes mellitus and hypertension for five years was admitted to the emergency unit with symptoms of fever, cough and dyspnoea. These symptoms were consistent with viral pneumonia and a COVID PCR test was performed, which tested positive three days later. The patient had chest pain on the eighth day of hospitalisation. On electrocardiography, simultaneous acute inferior and anterior STEMI were identified. High levels of stress and increased metabolic demand in these patients may lead to concomitant thrombosis of different coronary arteries, presenting with two different STEMIs.

Coronavirus disease 2019 (COVID-19) and simultaneous acute anteroseptal and inferior ST-segment elevation myocardial infarction.

Coronavirus disease 2019 (COVID-19) is a recently recognised pandemic spreading rapidly from Wuhan, Hubei, to other provinces in China and to many countries around the world. The number of COVID-19-related deaths is steadily increasing. Acute ST-segment elevation myocardial infarction (STEMI) is a disease with high morbidity and mortality rates, and primary percutaneous coronary intervention is usually recommended for the treatment. A patient with diabetes mellitus and hypertension for five years was admitted to the emergency unit with symptoms of fever, cough and dyspnoea. These symptoms were consistent with viral pneumonia and a COVID PCR test was performed, which tested positive three days later. The patient had chest pain on the eighth day of hospitalisation. On electrocardiography, simultaneous acute inferior and anterior STEMI were identified. High levels of stress and increased metabolic demand in these patients may lead to concomitant thrombosis of different coronary arteries, presenting with two different STEMIs.

Wolff-Parkinson-White Syndrome after Fontan-Bjork operation and its Successful Ablation from Coronary Sinus.

Wolff-Parkinson-White (WPW) syndrome causes paroxysmal supraventricular tachycardia in which short PR intervals and delta waves are seen in electrocardiography, which may cause sudden cardiac death. A 19-year female presented with increasing episodes of wide and narrow QRS complex tachycardia for the past 5 years. She had tricuspid atresia and Fontan Bjork operation in her past history. She was then diagnosed with narrow QRS complex tachycardia; and WPW syndrome was discovered when she returned to sinus rhythm. Ablation was performed from the coronary sinus ostium region via the left subclavian vein. Fontan Bjork procedure leading to accessory connections stemming from the surgery in the atrio-infundibular anastomosis may be one reason for WPW syndrome. In this case, since the ablation area was close to the Fontan anastomotic line, it could not be determined clearly whether WPW syndrome was secondary to Fontan anastomosis or it was congenital occult WPW syndrome, which became overt following Fontan surgery.

A patient with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA syndrome) and 13 live births.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) or Bland-White-Garland syndrome is a rarely seen congenital anomaly. Adult and infantile types are defined according to the degree of collateral development between the left coronary artery (LCA) and right coronary artery (RCA). If left untreated, ALCAPA has a 90% mortality rate in the first year of life, primarily due to myocardial ischaemia and heart failure. The degree of collateral development and the related LCA perfusion in ALCAPA syndrome determine the occurrence of symptoms. Herein, we present a case of a female patient who had previously, without any symptoms, given live birth to 13 babies. She had been experiencing exertional angina, which started long after the delivery of her 13th child. Since our patient had well-developed collaterals to the LCA, she was asymptomatic and able to give birth to the children via the vaginal route without any problems. Having well-formed collateral vessels between the RCA and LCA may prevent patients from developing symptoms, and even stressful conditions such as pregnancy may be tolerable.

Atrial Fibrillation Prediction by Surgical Risk Scores Following Isolated Coronary Artery Bypass Grafting Surgery.

OBJECTIVE: To compare surgical risk scores including Euroscore II, STS and Logistic Euroscore for their predictive ability about postoperative atrial fibrillation (POAF). STUDY DESIGN: Prospective cohort study. PLACE AND DURATION OF STUDY: Istanbul Yeni Yuzyil University, Gaziosmanpasa Hospital and Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, from June to December 2018. METHODOLOGY: One hundred and four patients, undergoing isolated coronary artery bypass grafting operation, were enrolled. Surgical risk scores, clinical, laboratory and echocardiographic parameters were compared between POAF-positive and POAF-negative groups Results: Of the 104 patients included, 23 (22.1%) patients developed atrial fibrillation postoperatively. Peripheral artery disease, carotid artery disease, current smoking, cardiopulmonary bypass time, left atrial diameter, and Syntax II score were found to be associated with POAF. Among these, peripheral artery disease and cardiopulmonary bypass time were independently related with POAF. Euroscore II (p = 0.005), STS (p = 0.026) and Logistic Euroscore (p = 0.032) were all statistically higher in POAF developing patients. In terms of ROC analysis, area under the curve was higher in Euroscore II (0.697) than STS and Logistic Euroscore (0.658 and 0.652, respectively). CONCLUSION: Euroscore II, STS and Logistic Euroscore were all associated with POAF development. However, Euroscore II could be a better option for the prediction of POAF.

The relationship between serum lipid parameters and renal frame count in hypertensive patients with normal renal functions.

OBJECTIVE: Atherosclerosis can contribute to renovascular disease, and high cholesterol level is an independent risk factor for disease progression. Renal frame count (RFC) is an objective angiographic method of measuring macrovascular blood flow in the main renal artery and its segmental branches. The aim of the present study was to demonstrate relationship between serum lipid parameters and RFC. METHODS: In this cross-sectional study, 116 hypertensive patients were allocated into 2 groups according to serum low-density lipoprotein (LDL) levels. Group 1 comprised 60 patients with LDL <130 mg/dL and Group 2 consisted of 56 individuals with LDL ≥130 mg/dL. The patients were also divided into 2 groups according to total cholesterol (TC) levels (52 patients in group with TC <200 mg/dL and 64 patients in group with TC ≥200 mg/dL). RESULTS: Group 2 had higher mean RFC than Group 1 (p<0.001). RFC of both kidneys in Group 2 was significantly higher than results in Group 1 (p<0.001 and p=0.023, respectively). We found similar significant results in comparison of TC-based patient groups. RFC had positive correlation with smoking, TC, and LDL (r=0.326, p=0.035; r=0.393, p=0.010; and r=0.386, p=0.012, respectively). In multivariate linear regression analysis, LDL, TC, smoking, and creatinine clearance were independent predictors of RFC. CONCLUSION: In conclusion, in hypertensive patients with normal renal function, LDL, TC, and smoking may be predictors of RFC and aggressive risk factor modification may help to reduce the risk of renal failure.

The relationship between elevated magnesium levels and coronary artery ectasia.

BACKGROUND: Coronary artery ectasia (CAE) without specific symptoms is the localised or diffuse swelling of the epicardial coronary arteries. Magnessium (Mg) plays an important role in cardiac excitability, vascular tonus, contractibility, reactivity and vasodilatation. In our research, we aimed to study the vasodilatory effect of Mg in the aetiopathogenesis of ectasia. METHODS: Patients identified during routine coronary angiograms in our clinic between January 2010 and 2013 were included in the study. Sixty-two patients with isolated CAE, 57 with normal coronary angiograms (NCA), 73 with severe coronary artery disease (CAD), and 95 with stenosis of at least one coronary artery and CAE (CAD + CAE) were included in the study. Serum Mg levels were measured in mg/dl after 12 hours of fasting. RESULTS: There were no statistically significant differences between the groups in terms of age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, family history of coronary artery disease and medications used. Serum glucose, thyroid stimulating hormone (TSH), urea, total cholesterol, triglyceride, low-density lipoprotein (LDL) cholesterol, sodium and potassium levels were similar in all groups. Serum Mg levels were 1.90 ± 0.19 mg/dl in patients with isolated CAE, 1.75 ± 0.19 mg/dl in those with CAD, 1.83 ± 0.20 mg/dl in those with CAD + CAE, and 1.80 ± 0.16 mg/dl in the NCA group. These results show that Mg levels were higher in ectasia patients with or without CAD. CONCLUSIONS: The histopathological characteristics of patients with CAE were similar to those with CAD. The specific mechanism of abnormal luminal dilatation seen in CAE however remains to be elucidated. Mg is a divalent cation with powerful vasodilatory effects. In our study, serum Mg levels were found to be statistically higher in ectasia patients with or without CAD.

Assessment of right ventricular systolic and diastolic parameters in pulmonary sarcoidosis.

The clinical manifestations of cardiac involvement are seen in about 5% of patients with sarcoidosis; however, the incidence of cardiac involvement is higher in the autopsy series. About 14% of patients with pulmonary sarcoidosis (PS) without known cardiac involvement had diastolic dysfunction.We aimed to determine the role of parameters of right ventricular (RV) systolic and diastolic function in patients with PS without evidence of cardiac symptoms. Our study population consisted of 28 patients with grades 1-4 PS and 24 healthy subjects. This study was a clinical prospective cohort study. RV end-diastolic area was found to be significantly higher in the PS group (p=0.032). RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE) were shown to be statistically lower in the PS group as compared to the control group (p<0.001). However, pulmonary arterial systolic pressure was significantly higher in the PS group (p=0.003). The tricuspid E velocity and E/A ratio were found to be significantly lower in the PS group (p=0.025 and 0.009, respectively), while the tricuspid A velocity and myocardial performance index (MPI) were found to be significantly lower in the control group (p=0.034 and 0.007, respectively). Early detection of cardiac involvement in PS is crucial because of the increased morbidity and risk of sudden cardiac death. RV diastolic Doppler parameters, tissue Doppler MPI, RVFAC and TAPSE are practical and cheap techniques in the diagnosis of cardiac involvement in patients with PS. A thorough transthorasic echocardiographic examination including RV systolic and diastolic functions and tissue Doppler MPI should constitute the mainstay of initial management and follow-up in PS.

Coronary Artery Disease Risk Factors, Coronary Artery Calcification and Coronary Bypass Surgery.

INTRODUCTION: Atherosclerosis is an intimal disease which affects large and medium size arteries including aorta and carotid, coronary, cerebral and radial arteries. Calcium accumulated in the coronary arterial plaques have substantial contribution to the plaque volume. The aim of our study is to investigate the relationship between coronary artery disease (CAD) risk factors and coronary arterial calcification, and to delineate the importance of CACS in coronary artery bypass surgery. MATERIALS AND METHODS: The current study is retrospective and 410 patients admitted to our clinic with atypical chest pain and without known CAD were included. These individuals were evaluated by 16 slice electron beam computed tomography with suspicion of CAD and their calcium scores were calculated. Detailed demographic and medical history were obtained from all of the patients. RESULTS: In our study, we employed five different analyses using different coronary arterial calcification score (CACS) thresold levels reported in previous studies. All of the analyses, performed according to the previously defined thresold levels, showed that risk factors had strong positive relationship with CACS as mentioned in previous studies. CONCLUSION: Coronary arterial calcification is part of the athero-sclerotic process and although it can be detected in atherosclerotic vessel, it is absent in a normal vessel. It can be concluded that the clinical scores, even they are helpful, have some limitations in a significant part of the population for cardiovascular risk determination. It is important for an anastomosis region to be noncalcified in coronary bypass surgery. In a coronary artery, it will be helpness for showing of calcific field and anostomosis spot.

Traumatic Coronary Artery Dissection in a Young Woman after a Kick to Her Back.

We present the case of a 38-year-old woman admitted to our outpatient clinic with accelerating back pain and fatigue following a kick to her back by her husband. Upon arrival, we detected ST segment elevation in the D1, aVL, and V2 leads and accelerated idioventricular rhythm. She had pallor and hypotension consistent with cardiogenic shock. We immediately performed coronary angiography and found a long dissection starting from the mid-left main coronary artery and progressing into the mid-left anterior descending (LAD) and circumflex arteries. She was then transferred to the operating room for surgery. A saphenous vein was grafted to the distal LAD. Since the patient was hypotensive under noradrenaline and dopamine infusions, she was transferred to the cardiovascular surgery intensive care unit on an extracorporeal membrane oxygenator and intra-aortic balloon pump. During follow-up, her blood pressure remained low, at approximately 60/40 mmHg, despite aggressive inotropic and mechanical support. On the second postoperative day, asystole and cardiovascular arrest quickly developed, and despite aggressive cardiopulmonary resuscitation, she died.

Endocarditis in Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE) Syndrome: The First in the Literature.

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) syndromes is a rarely seen multisystem disorder with autosomal recessive inheritance due to thymidine phosphorylase gene mutation. It is characterized by progressive external ophthalmoplegia and/or pitosis, progressive gastrointestinal dismotility and abdominal pain, postprandial emesis, cachexia, demyelinating peripheral neuropathy, symmetrical and distal weakness especially in lower extremities and diffuse leucoencephalopathy in cranial magnetic resonance. Endocarditis is the infectious and inflammatory disease of the endothelial surface of the heart. MNGIE syndrome is a condition in which immune system is suppressed and infection risk increased. Herein we summarized a previously not reported endocarditis case in a patient with MNGIE syndrome who was under follow up for three years. In MNGIE syndrome of acute dyspnea, infective endocarditis should be kept in mind and prompt evaluation for surgical treatment should be done.

Swallowed a needle stuck in heart.

Cardiac tamponade (CT) is a clinical entity characterized by hemodynamic insufficiency resulting from increased intrapericardial pressure due to accumulation of contents such as serous fluid, blood, and pus. CT is a treatable cause of cardiogenic shock, which can be fatal unless diagnosed promptly. Dyspnea, chest pain, hypotension, tachycardia, pulsus paradoxus, raised jugular venous pressure, muffled heart sounds, decreased electrocardiographic voltage, and enlarged cardiac silhouette on chest X-ray are the major clinical signs in CT. Idiopathic or viral pericardititis, iatrogenic trauma during percutaneous coronary interventions or coronary artery bypass grafting, external trauma, malignancies, acute or chronic kidney disease, collagen vascular diseases, tuberculosis, radiation on the chest wall, hypothyroidism and aortic dissection are the etiologic factors. Herein, we present a case of surgically treated CT, which was diagnosed in the third day of ingestion of a sewing needle.

Isolated absence of coronary sinus: two cases report.

Coronary sinus (CS) is the venous drainage system of the heart. Absence of the coronary sinus or atresia of ostium of the CS are rarely seen cardiac malformations. Congenital absence of CS usually is found together with other cardiac malformations, however, isolated congenital absence of CS is very rare. Multiple coronary-cameral fistulous connections, through which the blood drains into one of the cardiac chambers, are commonly seen in patients with CS abnormalities. Herein we present a case two cases of total absence of CS with a venous system draining directly into the left ventricle through Thebesian veins.

Surgical extraction of an embolized atrial septal defect occluder device into pulmonary artery after percutaneous closure.

An atrial septal defect is the most common type of congenital heart disease among adults. Surgical repair or percutaneous closure of the defect is the treatment options. Even though percutaneous closure seems to be less risky than surgical repair, it may result in fatal complications like device embolism, cardiac perforation and tamponade. Herein we report a case of the embolism of a device into the pulmonary artery after one hour of percutaneous closure in which the embolized device was surgically removed and the defect was closed with a pericardial patch.

Heart rate variability and heart rate turbulence in patients with chronic obstructive pulmonary disease.

BACKGROUND: In chronic obstructive pulmonary disease (COPD) patients, functional and structural changes of the respiratory system greatly influence cardiovascular autonomic functions. Determining autonomic balance may be important in understanding the pathophysiology of COPD and useful clinically in the treatment of COPD patients. Heart rate variability (HRV) and heart rate turbulence (HRT) are useful tools in assessing the autonomic neurovegetative function. Our aim in this study was to evaluate the HRV and HRT variables in COPD patients. Twenty five moderate to severe COPD patients and 25 healthy subjects were included in this study. METHODS: Pulmonary function tests and echocardiographic examination, arterial blood gases analysis were performed, HRV and HRT analysis were assessed from a 24-hour Holter recording. RESULTS: When HRV and HRT parameters were compared, COPD patients had significantly decreased sNN50 total, pNN50, SDANN, SDNN, SDNNI, rMSDD in time domain HRV parameters, and the values of the HRT onset was significantly less negative in COPD patients. Although the values of the HRT slope were lower in COPD patients, there was no significant difference between the two groups. We also found a correlation between HRT and HRV parameters. CONCLUSIONS: In addition to HRV parameters, HRT onset was significantly different in COPD patients. In our opinion, the combination of HRV variables and HRT onset may be simple and elegant ways of evaluating cardiac autonomic functions. New investigations of HRT and HRV in COPD patients have a potential importance for improving risk stratification and therapeutic approaches, and understanding the autonomic outcomes of the disease process.

A case of hypothyroidism mimicking acute coronary syndrome.

Hypothyroid patients have increased concentrations of creatinine kinase that is mostly due to increased CK-MM. However, CK-MB has also been reported to increase above reference values in hypothyroid patients without apparent myocardial damage. This may create confusion during the evaluation of myocardial injury in a hypothyroid patient presenting with chest pain. Troponin I is considered as a superior marker for the diagnosis of myocardial infarction in hypothyroid patients. However, there are some reports showing an increase in the level of troponin I without any myocardial damage in hypothyroid patients as in our case. In this report, we present a 47 years old male hypothyroid patient who had chest pain, abnormal electrocardiographic findings and increased cardiac enzymes suggesting acute coronary syndrome although he had normal coronary arteriogram.