Clinical and electrophysiological characteristics of typical atrioventricular nodal reentrant tachycardia in the elderly - changing of slow pathway location with aging.

BACKGROUND: The aim of this study was to retrospectively evaluate the clinical and electrophysiological characteristics of elderly patients with typical atrioventricular nodal reentrant tachycardia (AVNRT), and to assess the acute safety and efficacy of slow-pathway radiofrequency (RF) ablation in this specific group of patients. METHODS AND RESULTS: The present study retrospectively included a total of 1,290 patients receiving successful slow-pathway RF ablation for typical slow-fast AVNRT. Patients were divided into 2 groups: group I included 1,148 patients aged <65 years and group II included 142 patients aged >65 years. The required total procedure duration and total fluoroscopy exposure time were significantly higher in group II vs. group I (P=0.005 and P=0.0001, respectively). The number of RF pulses needed for a successful procedural end-point was significantly higher in group II than in group I (4.4 vs. 7.2, P=0.005). While the ratio of the anterior location near to the His-bundle region was significantly higher in group II, the ratio of posterior and midseptal locations were significantly higher in group I (P=0.0001). The overall procedure success rates were similar. There was no significant difference between the 2 groups in respect of the complications rates. CONCLUSIONS: This experience demonstrates that RF catheter ablation, targeting the slow pathway, could be considered as first-line therapy for typical AVNRT patients older than 65 years as well as younger patients, as it is very safe and effective in the acute period of treatment.

Left lateral free wall pathway ablation complicated by plaque rupture and acute occlusion of the left anterior descending coronary artery.

Radiofrequency (RF) ablation of accessory bypass tracts associated with the Wolff-Parkinson-White (WPW) syndrome has become the treatment of choice for many arrhythmias. Complications are unusual and acute coronary artery occlusion is very rare. We here present a 38-year-old male patient with an acute occlusion of proximal left anterior descending (LAD) coronary artery after RF ablation of a left free wall accessory pathway. An interesting feature is the site of the coronary artery occlusion which is remote from the RF application site. The occlusion was successfully treated with the placement of an intracoronary stent.

Disappearance of myocardial bridging of the left anterior descending coronary artery after inferior myocardial infarction.

Myocardial bridging (MB) is defined as the intramural course of a major epicardial coronary artery, and is mostly confined to the left ventricle and the left anterior descending coronary artery (LAD). MB is a common congenital abnormality of a coronary artery, and is usually thought to be a benign anatomical variant. Although rare, previous studies have reported that patients with MB may suffer from myocardial ischemia, myocardial infarction (MI), arrhythmias, and even sudden death. Therefore, the diagnosis and treatment of MB are both important. Since MB is congenital, its disappearance is unlikely. We here report a very rare case of disappearance of MB after inferior MI.

Myocardial infarction in a 17-year-old patient due to neurofibromatosis-associated coronary aneurysm.

Neurofibromatosis is an autosomal dominant multi-system genetic disorder. Extra-cardiac vascular manifestations of neurofibromatosis have been previously described in many reports. However, coronary arterial involvements have been rarely described. A 17-year-old girl with neurofibromatosis presented to our institute with subacute myocardial infarction. Coronary angiogram revealed an aneurysm with thrombus in the left anterior descending artery.

Aortic stiffness and flow-mediated dilatation in normotensive offspring of parents with hypertension.

OBJECTIVES: Although hypertension has been shown to be one of the most important risk factors for atherosclerosis, data about the presence of subclinical atherosclerosis in normotensive offspring with parental history of hypertension are scarce. Accordingly, the current study was designated to evaluate flow-mediated dilatation and aortic stiffness, which are early signs of atherosclerosis in young subjects with parental history of hypertension. METHODS: A total of 140 [corrected] healthy, non-obese subjects in the age group of 18-22 years were included in this study and divided into two groups. The first group included 70 offspring of hypertensive parents and the second group included 70 offspring of normotensive parents as controls. In all subjects, endothelium-dependent and endothelium-independent vasodilatation of the brachial artery and aortic elastic parameters were investigated using high-resolution Doppler echocardiography. RESULTS: Offspring of hypertensive parents demonstrated higher values of aortic stiffness (7.1 plus or minus 1.88 and 6.42 plus or minus 1.56, respectively) but lower distensibility (9.47 plus or minus 1.33 and 11.8 plus or minus 3.36 square centimetres per dyne per 106) and flow-mediated dilatation (4.57 plus or minus 1.3 versus 6.34 plus or minus 0.83 percent, p equals 0.0001, respectively) than offspring of hypertensive parents. CONCLUSION: We observed blunted endothelium-dependent dilatation and aortic stiffness in offspring of hypertensive parents compared with offspring of normotensive [corrected] parents. This is evident in the absence of overt hypertension and other diseases, suggesting that parental history of hypertension is a risk for subclinical atherosclerosis and it may contribute to the progression to hypertension and overt atherosclerosis in later life.

Single coronary artery originating from the right sinus of Valsalva and hypoplastic left anterior descending artery: An extremely rare combination of congenital coronary artery anomalies.

A 57-year-old woman with a history of hypertension, hyperlipidemia and stable angina is described. A coronary angiogram revealed the presence of a single coronary artery arising from the right sinus of Valsalva that was providing the left anterior descending (LAD), left circumflex and right coronary artery branches, with noncritical occlusive atherosclerotic plaques at the proximal circumflex artery. A small hypoplastic LAD tapering proximally was found, but no LAD and compensatory collateral circulatory vessels were observed distally. In the present report, the authors discuss this extremely rare combination of congenital coronary anomalies and their clinical implications.

Aortic pressures, stiffness and left ventricular function in coronary slow flow phenomenon.

BACKGROUND: Coronary slow flow (CSF) phenomenon is characterized by delayed opacification of coronary vessels in a normal coronary angiogram. Although clinical and pathological features have been previously described, the underlying pathophysiology has not been fully elucidated. In this study, we aimed to evaluate central aortic pressure, aortic stiffness and left ventricular (LV) function in patients with coronary slow flow. METHOD AND RESULTS: The study population consisted of 154 patients who underwent coronary angiography because of typical and quasi-typical symptoms of angina. 81 patients with angiographically proven CSF and 73 cases with normal coronary flow pattern with similar risk profiles were enrolled in the study. Aortic pressures and indexes of elastic properties were evaluated using invasive methods. Aortic pulse pressure (mm Hg) and pulsality index of patients with CSF were found to be significantly higher than those of controls (60.8 ± 13.8 vs. 53.7 ± 14.5, p = 0.002; 0.84 ± 0.22 vs. 0.67 ± 0.18, p = 0.0001, respectively). LV Doppler parameters were deteriorated in patients with CSF. Aortic fractional pulse pressure and pulsality index were significantly correlated with the mean TIMI frame count and LV diastolic parameters in correlation analysis. CONCLUSION: The present findings allow us to conclude that impaired aortic elasticity in patients with CSF may also be responsible for the impaired LV diastolic parameters.

Massive right atrial myxoma causing right ventricular inflow obstruction: an unusual presentation of myxoma.

We describe a case of a massive right atrial myxoma, causing right ventricular inflow obstruction. The tumor was detected by echocardiography and resected along with a section of the tricuspid septal leaflet, followed by primary repair, resulting in relief of her symptoms.

Simvastatin may improve myocardial perfusion abnormality in slow coronary flow.

BACKGROUND: The slow coronary flow (SCF) phenomenon is a coronary microvascular disorder characterized by the delayed passage of contrast in the absence of obstructive epicardial coronary disease. Recent studies showed the possible role of endothelial dysfunction, diffuse atherosclerosis and inflammation in the pathogenesis of this phenomenon. We aimed to investigate the effect of statin on myocardial perfusion in patients with SCF. METHODS AND RESULTS: The study population consisted of 97 patients with SCF. Coronary flow patterns of the cases are determined by thrombolysis in myocardial infarction (TIMI) frame count method. Single-photon emission computed tomographic myocardial perfusion imaging studies and lipid parameters of the patients were obtained before and after 6 months of simvastatin treatment period. During the study, daily single dose of 40 mg simvastatin has been given to each subject. We found a significant positive correlation between mean TIMI frame count and basal reversibility score (r = 0.84, p = 0.0001). In addition, analysis of the reversibility scores demonstrates that simvastatin treatment has significantly improved the myocardial perfusion abnormality at the end of the follow-up period. CONCLUSION: Present findings allow us to conclude that simvastatin improved myocardial perfusion in patients with SCF.

Oxidative stress parameters in patients with slow coronary flow.

INTRODUCTION: We investigated the probable role of free-radical damage in the pathogenesis of slow coronary flow (SCF) by using oxidative stress parameters. METHODS: Sixty-four patients with angiographically proven SCF and 63 patients with normal coronary flow (NCF) pattern with similar risk profiles were enrolled in this study. We measured erythrocyte superoxide dismutase (SOD), reduced glutathione (GSH), serum malondialdehyde (MDA), catalase and myeloperoxidase (MPO) levels in all subjects. RESULTS: There were statistically significant differences in the levels of erythrocyte SOD, GSH and serum MDA between the 2 groups. Serum MDA (P = 0.003) and erythrocyte SOD levels (P = 0.0001) were increased in the SCF group. The level of erythrocyte GSH (P = 0.010) was lower in patients with SCF. There were no differences between the groups' serum catalase (P = 0.682) and MPO levels (P = 0.070). CONCLUSION: Our data showed that in patients with SCF, serum MDA and erythrocyte SOD levels were increased while erythrocyte GSH levels were decreased significantly, compared with NCF patients. These results indicate that free-radical damage may play a role in the pathogenesis of SCF.

How Do Patients Understand Safety for Cardiac Implantable Devices? Importance of Postintervention Education.

AIM: This study was designed to assess the effect of patient education on the knowledge of safety and awareness about living with cardiac implantable electronic devices (CIEDs) within the context of phase I cardiac rehabilitation. METHODS: The study was conducted with 28 newly implanted CIED patients who were included in "education group (EG)". Patients were questioned with a survey about living with CIEDs and electromagnetic interference (EMI) before and 1 month after an extensive constructed interview. Ninety-three patients who had been living with CIEDs were included in the "without education group (woEG)". RESULTS: Patients in EG had improved awareness on topics related to physical and daily life activities including work, driving, sports and sexual activities, EMI of household items, harmful equipment, and some of the medical devices in the hospital setting (p<0.05). Patients in EG gave significantly different percent of correct answers for doing exercise or sports, using the arm on the side of CIEDs, EMI of some of the household appliances, medical devices, and all of the harmful equipment compared to woEG (p<0.05). CONCLUSION: It was demonstrated that a constructed education interview on safety of CIEDs and living with these devices within the context of phase I cardiac rehabilitation is important for improving the awareness of patients significantly. Thus, patients might achieve a faster adaptation to daily life and decrease disinformation and misperceptions and thus promote the quality of life after the device implantation.

Correction to: Impaired coronary blood flow may be related to elevated homocysteine levels in patients with metabolic syndrome.

Correction to: Wien Klin Wochenschr 2015 https://doi.org/10.1007/s00508-015-0854-z The original version of this article unfortunately contained a mistake. The first names of Dr. Ismail Dogu Kilic were interchanged.

Interaction of plasma homocysteine and thyroid hormone concentrations in the pathogenesis of the slow coronary flow phenomenon.

BACKGROUND AND OBJECTIVE: The slow coronary flow (SCF) phenomenon is an angiographic observation and a well-recognized clinical entity characterized by delayed opacification of vessels in a normal coronary angiogram due to reasons yet unclear. Thyroid hormones exert significant effects on plasma homocysteine (Hcy) levels and microvascular resistance. Recently, several investigators have consistently reported that elevation of the plasma Hcy level can severely disturb vascular endothelial function and play a role in the pathogenesis of SCF. Accordingly, we investigated the levels of plasma Hcy and thyroid hormones and their relationship in patients with SCF. METHOD: Forty-four patients with angiographically proven SCF (Group I) (mean age 55.5 +/- 10.4 years, 26 males) and 44 cases with normal coronary flow (NCF) pattern (Group II) (mean age 53.9 +/- 11 years, 22 males) with similar risk profiles were enrolled in the study. Coronary flow patterns of the cases were determined by the thrombolysis in myocardial infarction (TIMI) frame count method. The coronary TIMI frame counts were calculated separately for each coronary artery and their average was determined as the mean TIMI frame count for each subject. Serum levels of free tri-iodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormone (TSH) and Hcy were measured. Patients with thyroid disease or on medications with a potential to affect thyroid functions were excluded. RESULTS: There were no statistically significant differences between the groups concerning the demographic characteristics and major cardiovascular risk factors. Mean TIMI frame counts of SCF and NCF groups were 45.9 +/- 12 and 23.3 +/- 3.7, respectively. fT4 (ng/dl) and TSH (microIU/ml) levels of the two groups were similar (p > 0.05). The level of fT3, the active metabolite of the thyroid hormone family, was dramatically reduced in the SCF group when compared to the NCF group (2.3 +/- 0.2 vs. 3.0 +/- 0.3, p = 0.0001, respectively). Plasma Hcy levels of patients with SCF were found to be significantly higher than controls (12.2 +/- 4.9 vs. 8.5 +/- 2.9, p = 0.0001, respectively). Correlation analysis showed a significant negative correlation between the plasma fT3 and Hcy levels and the mean TIMI frame counts (r = -0.31, p = 0.003 vs. r = -0.66, p = 0.0001). Moreover, there was a significant positive correlation between the plasma Hcy levels and the mean TIMI frame counts (r = 0.58, p = 0.0001). Also, fT3 was the only significant determinant of the variance of Hcy in multiple regression analysis (r = -0.30, p = 0.005). CONCLUSION: fT3 levels were decreased and plasma Hcy levels were increased significantly in patients with SCF as compared to controls. This finding suggests that thyroid hormones and/or (?) a possible disturbance in their metabolism may be responsible for the elevated levels of plasma Hcy in patients with SCF and may play a role in the pathogenesis of the SCF phenomenon.

Effect of homocysteine-induced oxidative stress on endothelial function in coronary slow-flow.

BACKGROUND AND OBJECTIVE: Coronary slow-flow (CSF) phenomenon is characterized by delayed opacification of vessels in a normal coronary angiogram, but its etiopathogenesis remains unclear. Plasma homocysteine (Hcy) level can severely disturb vascular endothelial function and may play a role in the pathogenesis of CSF. In our study, endothelial function in patients with CSF and their relationship with Hcy and oxidative stress parameters are investigated. METHOD: Forty-four patients with angiographically proven CSF and 44 cases with normal coronary flow pattern with similar risk profile were enrolled in the study. Coronary flow patterns of the cases are determined by Thrombolysis in Myocardial Infarction (TIMI) frame count method. Endothelium dependent flow mediated dilatation (FMD) and independent vasodilatation characteristics are evaluated by high frequency ultrasound over the brachial artery. Superoxide dismutase (SOD) and reduced glutathione (GSH) and reduction of oxidative material in the body and the end product of lipid peroxidation, malondialdehyde (MDA) are measured as oxidative stress markers in blood samples. RESULTS: Plasma Hcy level (micromol/l) of patients with CSF was found to be significantly higher than in controls (12.2 +/- 4.9 vs. 8.5 +/- 2.8, p = 0.0001). FMD was 7.87 +/- 2.0% in controls and 4.98 +/- 1.1% in patients with CSF (p = 0.0001). GSH was reduced in patients with CSF. SOD and MDA activity were found higher in patients with CSF than control subjects. Plasma Hcy level was significantly positively correlated with mean TIMI frame count and negatively correlated with FMD in correlation analysis (r = 0.58, p = 0.0001; r = -0.41, p = 0.022; respectively). CONCLUSION: The present findings allow us to conclude that patients with CSF have increased levels of Hcy and oxidative stress markers and impaired endothelial cell function.

Deteriorated Systolic Blood Pressure Recovery and Heart Rate Recovery After Graded Exercise in Children With Familial Mediterranean Fever.

OBJECTIVES: This study aims to investigate if cardiac involvement may occur in children with familial Mediterranean fever (FMF) without cardiovascular symptoms by using heart rate recovery (HRR) and systolic blood pressure recovery (SBPR) parameters. PATIENTS AND METHODS: A total of 50 FMF patients (26 males, 24 females; mean age 151±33.4 month; range 60 to 216 month) and 30 healthy controls (18 males, 12 females; mean age 143±43.9 month; range 84 to 228 month) were included in the study. All patients were evaluated by echocardiography. All patients underwent a maximal graded exercise stress test. HRR and SBPR parameters were calculated. RESULTS: There was a significant decrease in HRR1 value in FMF group (p=0.03). SBPR1 and SPBR2 values were higher in FMF group compared to control group (0.96±0.12 vs 0.88±0.12 and 0.95±0.09 vs 0.91±0.11, respectively); and the high SBPR1 value was statistically significant (p=0.02). FMF presence had a negative correlation with HRR1 (r= -0.26, p=0.03) and a positive correlation with SBPR1 (r=0.29, p=0.02). There was a negative correlation of M694V homozygous mutation with HRR1 and HRR2 values (r= -0.43, p=0.004, r=-0.42, p=0.005). CONCLUSION: Cardiac involvement may occur in FMF patients without cardiovascular symptoms. Impaired SBPR and decreased HRR response may indicate increased cardiovascular risk in these patients despite normal exercise stress test results.

The antiarrhythmic effect and clinical consequences of ischemic preconditioning.

Potentially hazardous short ischemic episodes increase the tolerance of myocardium to ischemia paradoxically. This condition decreases the infarct area markedly caused by a longer duration of coronary occlusion. This phenomenon is known as 'ischemic preconditioning' and its powerful cardioprotective effect has been shown in experimental and clinical studies. Ischemic preconditioning decreases cardiac mortality markedly by preventing the development of left ventricular dysfunction and ventricular and supraventricular arrhythmias after acute myocardial infarction. Ischemia-induced opening of ATP-sensitive potassium channels and synthesis of stress proteins via activation of adenosine, bradykinin and prostaglandin receptors seem to be the possible mechanisms. By understanding the underlying mechanisms of ischemic preconditioning, it may be possible to develop new pharmacologic agents that cause ischemic preconditioning with antiischemic and antiarrhythmic properties without causing myocardial ischemia.

Carotid intima-media thickness in coronary slow flow: relationship with plasma homocysteine levels.

BACKGROUND AND OBJECTIVE: Coronary slow-flow phenomenon is characterized by delayed opacification of coronary vessels in a normal coronary angiogram. Although clinical and pathological features have been previously described, the underlying pathophysiology has not been fully elucidated. Thus, it still remains to be determined whether either microvascular or epicardial diffuse atherosclerotic disease is related to slow flow. In this study, we aimed to determine the carotid artery intima-media thickness, which is a marker of atherosclerosis in patients with coronary slow flow, and its possible relationship with the total homocysteine level. METHOD: The study population consisted of 88 patients who underwent coronary angiography because of typical and quasi-typical symptoms of angina. Forty-four patients with angiographically proven coronary slow flow and 44 individuals with normal coronary flow pattern with similar risk profiles were enrolled in the study. Coronary flow patterns of the latter were determined by the thrombolysis in myocardial infarction frame count method. Intima-media thickness was measured by recording ultrasonographic images of both the left and the right common carotid artery with a 12-MHz linear array transducer. Plasma homocysteine, folate and B12 levels were measured from blood samples. RESULTS: Plasma homocysteine levels (mumol/l) and carotid intima-media thickness (mm) of patients with coronary slow flow were found to be significantly higher than that of controls (12.4+/-4.9 vs. 8.5+/-2.8, P=0.0001; 0.75+/-0.08 vs. 0.69+/-0.06, P=0.0001, respectively). The plasma folate level (ng/ml) was lower in coronary slow-flow patients than in controls (13.8+/-4.4 vs. 16.5+/-5.6, P=0.014). The plasma homocysteine level was significantly positively correlated with the mean thrombolysis in myocardial infarction frame count and intima-media thickness of the carotid artery in correlation analysis (r=0.58, P=0.0001; r=0.41, P=0.0001; respectively). CONCLUSION: Homocysteine levels and carotid intima-media thickness increased but folate levels decreased in patients with coronary slow flow. The present findings allow us to conclude that the possible disturbance in the metabolism of homocysteine in patients with coronary slow flow may have a role in the etiopathogenesis of this phenomenon by causing generalized atherosclerosis.

Preservation of pleural integrity in patients undergoing coronary artery bypass grafting: effect on postoperative bleeding and respiratory function.

OBJECTIVE: The purpose of this study was to evaluate the influence of preserved integrity of pleura on postoperative bleeding and respiratory function in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: Seventy-two CABG patients who received pedunculated IMA graft without opening the pleura (group of intact pleura, group IP) between July 2002 and September 2004 were matched to 72 CABG patients who received pedunculated IMA graft with opened pleura (group of opened pleura, group OP). To match the patients with IP and unique patients with OP, logistic regression was used to develop a propensity score. The C statistic for this model was 0.79. Patients with IP were matched to unique patients with OP with an identical 5-digit propensity score. If this could not be done, we proceeded to a 4-, 3-, 2-, or 1-digit match. Patients characteristics were well matched. There were no differences in preoperative and peroperative variables between the groups. The incidence of postoperative pleural effusion and thoracentesis were significantly lower in group IP than group OP (pleural effusion in 15.2 versus 30.5%; p = 0.029, thoracentesis in 5.5 versus 18.5%; p = 0.036). Other pulmonary complications such as prolonged ventilation, reintubation, pneumothorax, atelectasis, diaphragmatic paralysis were similar in both groups. Patients with IP had significantly lower blood loss (520 versus 870 ml; p < 0.001) and whole blood unit transfusion (26.3 versus 41.6%, p = 0.036). Also, intensive care unit and hospital stay were similar in both groups. CONCLUSIONS: Meticulous internal mammary artery harvesting and preservation of the pleural integrity significantly reduces postoperative bleeding and pleural effusion.

Iatrogenic cardiac herniation and torsion after surgery for a penetrating cardiac injury.

Cardiac herniation and torsion is a rare condition associated with a high mortality rate. We present an unusual case of sudden cardiogenic shock that was caused by torsion and herniation of the heart after an operation for a penetrating cardiac injury. The patient was successfully treated by urgent surgical intervention.