Two-dimensional speckle-tracking echocardiography-based left atrial strain parameters predict masked hypertension in patients with hypertensive response to exercise.

OBJECTIVE: We aim to study left atrial (LA) strains in patients with hypertensive response to exercise (HRE) and determine their usefulness in predicting masked hypertension (HT). METHODS: Ninety-eight normotensive patients who had HRE were included and were divided into two groups after masked HT had been diagnosed by ambulatory blood pressure monitoring. Conventional echocardiographic parameters and two-dimensional speckle-tracking echocardiography-based LA strain parameters were compared. RESULTS: Patients with masked HT have higher left ventricle mass index (LVMI) (88.1±11.3 vs. 82.5±8.7 g/m, P<0.05), left atrium maximum volume index (LAVI) (34.5±5.1 vs. 30.2±5.6 ml/m, P<0.001), lower global longitudinal LA strain during ventricular systole (GLAs-res) (32.5±8.9 vs. 40.2±9.1%, P<0.001), and lower global longitudinal LA strain during late diastole (GLAs-pump) (15.8±4.1 vs. 18.1±5.8%, P<0.05). In univariate analysis, a good negative correlation was found between GLAs-res versus LAVI (r=-0.451, P<0.001), GLAs-res versus LVMI (r=-0.457, P<0.001) and a moderate negative correlation was present between GLAs-pump versus LAVI (r=-0.317, P<0.001) and GLAs-pump versus LVMI (r=-0.288, P<0.05). GLAs-res and LAVI were found to be independent predictors of masked HT. Receiver-operating characteristic analysis was carried out. Area under the curve to predict masked HT was 0.729 (95% confidence interval: 0.623-0.832, P<0.001). GLAs-res less than 33.1% predicted masked HT with 73% sensitivity and 61.5% specificity. CONCLUSION: LA strain parameters were impaired in patients with masked HT and can be used to predict the presence of masked HT in patients with HRE.

Pseudohypoparathyroidism presenting with ventricular arrhythmia: a case report.

Pseudohypoparathyroidism (PHP) is a rare disorder characterized by varying degrees of unresponsiveness to parathyroid hormone. Patients usually present with hypocalcemia-induced seizures or tetany, whereas no case of hypocalcemia-induced cardiac arrhythmia in PHP has been described to date. In this paper, we report the case of a male adolescent with PHP type 1a who presented with hypocalcemia-induced ventricular extrasystoles (bigeminy, trigeminy) and mild corrected QT interval prolongation. The patient had brachydactyly and his second fingers and toes were longer than the others, a finding consistent with PHP. Laboratory tests detected hypomagnesemia, as well as elevated levels of creatine kinase and lactate dehydrogenase. Ventricular arrhythmia and abnormal laboratory tests improved with calcium supplementation and vitamin D treatment. The findings in this patient suggest that hypomagnesemia may make patients with PHP more susceptible to hypocalcemia and may thus prompt a state of hypocalcemia-induced arrhythmia or other cardiac complications.

Mean platelet volume in functional and thrombotic prosthetic mitral valve.

The mean platelet volume (MPV) values reflect platelet size and are accepted as marker of platelet activation. We sought to test the hypothesis that platelet activation occurs independently from presence or absence of thrombus in prosthetic mitral valve. A total of 168 patients were included in the study. Study participants were divided in three groups: group 1 (n = 62) - patients with normal prosthetic mitral valve; group 2 (n = 37) - patients with prosthetic mitral valve thrombosis; and group 3 (n = 69) - healthy individuals. MPV values were significantly higher in normal and thrombotic prosthetic mitral valve patients than in healthy individuals (P = 0.008 and P = 0.01, respectively). MPV values were not different between normal prosthetic mitral valve and thrombotic prosthetic mitral valve. This is the first study indicating that increased MPV is present in normal and thrombotic prosthetic mitral valve, implying that platelet reactivity occurs in prosthetic mitral valve irrespective of development of thrombus formation.

Clinical outcomes of mitral valve repair in mitral regurgitation: a prospective analysis of 100 consecutive patients.

OBJECTIVE: Mitral valve repair has become the procedure of choice for almost every type of mitral regurgitation (MR) in the current surgical era. We assessed clinical outcomes of mitral valve repair in severe MR. METHODS: In this prospective cohort study, 103 patients (61 male, 42 female, mean age 53.2±14.8 years), who were planned to undergo valve repair were included. Mitral valve pathology was regurgitant in 86% and mixed in 14% of patients. The intention to perform mitral repair was successful in 100 (97.1%) of patients. Concomitant procedures were performed in 57 (57%) patients including 31 coronary artery bypass grafting and 13 tricuspid valve repairs. After surgery, early (<30 days) and late (>30 days) complications were recorded. Postoperative echocardiography was performed in all patients at discharge and during clinical follow-up. Late survival and freedom from adverse events including thromboembolism, endocarditis, reoperation, and residual severe MR were estimated by using the Kaplan-Meier survival analysis. RESULTS: There was no early mortality. Echocardiographic assessment of patients at discharge revealed no/trivial regurgitation in 89% and mild (1+) MR in 11% of all patients. Late mortality occurred in only one patient at 14 months because of renal failure. The mean follow-up period of patients was 21.2±10.3 months. Echocardiographic examination during follow-up revealed that mitral insufficiency was none or mild in 96% of patients. Three (3%) patients had moderate (2+) MR and were treated medically. Mitral insufficiency recurrence with severe (3+) regurgitation occurred in one (1%) patient undergoing coronary artery revascularization and concomitant left ventricular aneurysmectomy. Re-operation was needed in only one (1%) case because of infective endocarditis that was treated with mechanical valve replacement. Kaplan-Meier estimates were 99±2.7% for late survival and 98±2.2%, 99±2.7%, 99±2.7% and 99±0.9% for freedom from thromboembolism, endocarditis, reoperation, and residual severe MR, respectively. CONCLUSION: This study showed that mitral valve repair provides excellent surgical outcomes. Repair procedures are safe, and highly effective, but operations require a considerable surgical experience.

Interrupted aortic arch in an adolescent male.

Interrupted aortic arch (IAA) is an uncommon and usually lethal congenital malformation. The present report describes an unusual case of IAA, an aneurysmal ascending aorta and a bicuspid aorta in a 15-year-old boy. He presented with general malaise, weakness of his legs, headache and hypertension that began six months earlier. He had suffered from effort intolerance since childhood. A three-dimensional gadolinium contrast-enhanced magnetic resonance angiogram demonstrated IAA and a markedly developed collateral circulation. IAA is an uncommon disease that is rarely encountered in an adolescent patient with nonspecific symptoms or hypertension. The present case also shows the clinical value of three-dimensional gadolinium contrast-enhanced magnetic resonance angiography for noninvasive assessment of the aortic arch, and magnetic resonance angiography can replace angiography in the assessment of aortic arch anomalies and visualization of well-developed collaterals.

Large ascending aortic aneurysm and severe aortic regurgitation in a 7-year-old child with Marfan syndrome and a review of the literature. Marfan syndrome in childhood.

A 7-year-old girl was admitted because of dyspnea on exertion and palpitations. Her symptoms had gradually worsened for the last 6 months. She had physical features of the Marfan syndrome. Transthoracic echocardiography showed an ascending aortic aneurysm, severe aortic regurgitation, and mildly dilated left ventricle. Because of marked aortic aneurysm and severe aortic regurgitation, the patient was treated with a beta-blocker and an angiotensin converting enzyme inhibitor. Surgery was refused by her parents. We describe here a child with Marfan syndrome in whom significant dilatation of the ascending aorta and severe aortic regurgitation is encountered and major cardiovascular complications of Marfan syndrome were reviewed.

QT dispersion in the risk stratification of patients with unstable angina: correlation with clinical course, troponin T and scintigraphy.

OBJECTIVE: This study sought to evaluate the potential prognostic usefulness of QT dispersion (QTd) in patients with unstable angina. METHODS AND RESULTS: QTd was calculated and plasma troponin T (TnT) level was measured and rest perfusion imaging with Tc-99m sestamibi was performed in 62 patients admitted with chest pain at rest. All patients had a follow-up during one month in order to assess cardiac events. Cardiac events occurred in 41 patients (no deaths, 11 myocardial infarctions (MI), 4 urgent and 26 planned revascularizations). The mean QTd in patients with cardiac events was significantly higher than in those without cardiac events (68 +/- 28 vs. 54 +/- 14 ms; p = 0.01). When patients were divided into subgroups according to the cardiac events, the mean QTd in MI and revascularization were 90 +/- 25 ms and 60 +/- 25 ms, respectively. QTd in patients with MI was higher than in patients without cardiac events (p = 0.001). There was no significant difference in QTd between the revascularization subgroup and patients without cardiac events. Nineteen patients with elevated TnT had a greater QTd compared to patients with normal TnT (74 +/- 29 vs. 56 +/- 20 ms; p = 0.008). Additionally, the mean QTd in 46 patients with perfusion defects was slightly higher than in patients without (66 +/- 27 vs. 53 +/- 17 ms; p = 0.03). There was also a moderate correlation between QTd and the number of perfusion defects (r = 0.31, p = 0.01). On the other hand, most of the patients who had a MI or urgent revascularization had a QTd greater than 75 ms. CONCLUSION: The measurement of QTd in patients with unstable angina may help to stratify patients at high risk for cardiac events, in particular MI and urgent revascularization.

Mitral annular calcification is associated with osteoporosis in women.

BACKGROUND: Few studies have suggested association between mitral annular calcification (MAC) and osteoporosis in women who are post-menopausal. However, the association of MAC with osteoporosis in women, in relation to bone resorption, as assessed by using the dual-energy x-ray absorptiometry method (DEXA), have not been performed. We sought to examine the association between MAC and osteoporosis. METHODS: In this prospective, observational study carried out in a tertiary referral center, 340 women (mean age +/- SD, 56 +/- 10 years; age range, 33-85 years) underwent echocardiography, with specific assessment of MAC and bone mineral density measurement (T-scores) using DEXA. RESULTS: MAC was absent in 123 patients (group I) and present in 217 patients (group II). Compared with the control group, the group with MAC had a significantly higher prevalence and severity of osteoporosis (18.2% vs 55.5%, P <.001). Severe osteoporosis was significantly more common in the severe MAC subgroup (n = 66) than in the control subjects (65.2% vs 17.1%; Pearson chi2, 70.02; df = 4; P <.001). With multivariate analysis, only T-scores and age were highly predictive of MAC, with an odds ratio of 2.66 (95 % CI, 1.85-3.83) and 1.04 (95% CI, 1.01-1.07), respectively. CONCLUSIONS: MAC is associated with osteoporosis. Bone mineral density measurement (T-scores) and age were highly predictive of MAC in women.

Right atrial 'thrombus in transit' and atrial septal defect in a 70-year-old man: cardioembolic source of pulmonary and paradoxical cerebral embolization.

A 70-year-old man was admitted with sudden onset of dyspnea, near syncope and left hemiparesis. Clinical examination, blood gas analysis, ECG and the chest X-ray were consistent with pulmonary embolism. Transthoracic echocardiography (TTE) revealed right atrial free-floating thrombus, large atrial septal defect (ASD), right heart enlargement and pulmonary artery hypertension. Anticoagulation therapy was initiated immediately, soon after thrombolytic therapy was started but the patient died due to possible pulmonary or cerebral embolization. We underscore rapid diagnosis by TTE that revealed right heart thrombus in transit and large ASD.

Acute rest perfusion imaging in high risk unstable angina: association with troponin T and clinical endpoints.

BACKGROUND: Troponin T (TnT) and rest perfusion imaging (RPI) have been reported to be important diagnostic tools for risk stratification in patients with chest pain. METHODS: We investigated the association between two methods in 60 patients presenting with typical chest pain at rest within the last 6 h before admission. All patients underwent Tc-99m gated SPECT imaging and serial TnT measurements and were followed for occurrence of adverse cardiac events up to 30 days. RESULTS: Perfusion defect was detected in 42 patients and elevated TnT was observed in 23 patients. All of the patients with an elevated TnT have also perfusion defect in RPI. Half of the patients with normal TnT level (51%) presented a perfusion defect detected by RPI (p = NS). The patients with elevated TnT levels had more perfusion defect numbers than those with normal TnT levels (8.2 +/- 2.9 vs. 5.3 +/- 2.2; p = 0.0007). Cardiac events occurred in 38 patients (14 MI, 24 revascularisation). In predicting cardiac events, RPI and TnT had sensitivities (97 vs. 58%; p < 0.001), specificities (77 vs. 95%, p = NS), positive predictive values (PPV) (88 vs. 96%; p = NS) and negative predictive values (NPV) (94% vs. 57%; p = NS), respectively. In predicting MI, the two tests had sensitivities (93 vs. 93%; p = NS), specificities (37 vs. 78%; p < 0.001), PPVs (31 vs. 57%; p = NS) and NPVs (94 vs. 97%; p = NS), respectively. CONCLUSIONS: These results suggest that in patients with rest angina (1) TnT elevation is associated with the extent of myocardial perfusion defect; (2) both tests are valuable, while positive RPI is more sensitive in predicting all cardiac events irrespective of TnT; both positive TnT and positive RPI predict a high probability to have MI; (3) both negative test results predict a very low probability to have cardiac event, including MI.

Effect of homocysteine-lowering therapy on vascular endothelial function and exercise performance in coronary patients with hyperhomocysteinaemia.

OBJECTIVE: This study was performed to determine the effect of homocysteine-lowering therapy (HLT) on endothelium-dependent vasodilation (EDD) and exercise performance in patients with coronary artery disease. METHODS AND RESULTS: Among the patients who were on the waiting list for coronary intervention, 26 male patients (plasma homocysteine (Hcy) levels > 15 micromol/l) who had a focal stenosis of at least 70% in the left anterior descending artery were included in the study. The patients were matched to receive HLT (n = 15; 0.4 mg of folic acid, 2 mg vitamin B6 and 6 microg of vitamin B12) or placebo (n = 11) until the coronary intervention was performed (mean 3.8 +/- 0.9 weeks). Brachial artery vasomotion test and treadmill stress testing were performed at baseline and 4 weeks after HLT before the time of coronary intervention in each patient. Hcy levels were found to be decreased significantly after HLT compared to baseline (23.4 +/- 6 vs. 11.3 +/- 4 micromol/l; p < 0.001) whereas placebo had no effect. HLT but not placebo produced a marked improvement in EDD, from 3.9 +/- 1.1% to 9.4 +/- 2.3% (p < 0.0001). Endothelium-independent nitroglycerin-induced dilation was similar in the HLT and placebo groups compared with the baseline. In the exercise testing, HLT resulted in a significant improvement in exercise duration and reduction in the amount of maximal ST-segment depression, (from 6.5 +/- 2 to 6.9 +/- 2 min, p = 0.02 and from 1.2 +/- 0.7 to 0.8 +/- 0.5 mm, p = 0.01, respectively) whereas placebo did not. CONCLUSION: Lowering Hcy levels improves EDD and exercise performance while reducing the exercise-induced myocardial ischaemia in patients with coronary heart disease and hyperhomocysteinaemia.

Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis.

A 53-year-old man with a history of repair of atrial septal defect 3-months ago by primary suture was admitted to an emergency department with sudden onset chest pain and dyspnea. Transthoracic echocardiography revealed a large and mobile thrombus attached to the right side of the interatrial septum. The chest X ray and perfusion lung scan established the diagnosis of the multiple pulmonary emboli. Doppler examination of the venous system for a possible source of thrombus was unremarkable. The postoperative early appearance of thrombus and multiple pulmonary emboli defects at lung scan supported that thrombus was originated from the primary suture site. Thrombolytic treatment achieved complete resolution of the thrombus both in the pulmonary artery and at the repaired septal defect site. The patient was placed on warfarin and thrombus was not detected by transesophageal echocardiography at the 9-month follow-up.

Angiotensin-converting enzyme gene polymorphism and coronary heart disease in Turkish type 2 diabetic patients.

OBJECTIVE: It has been suggested that the insertion (I)/deletion (D) polymorphism of the angiotensin-converting enzyme (ACE) may be associated with atherosclerosis. The aim of the study was to examine the association between ACE gene polymorphism and coronary heart disease in Turkish type 2 diabetic patients. METHODS AND RESULTS: A total of 152 (97 female, 55 male) type 2 diabetic patients were included into the study. All patients underwent myocardial perfusion scintigraphic examination and forty-five of them with a perfusion defect underwent coronary angiography.Thirty-eight patients with a coronary stenosis of more than 50% on coronary angiography were considered as having coronary heart disease. The I/D polymorphism was determined by polymerase chain reaction. There was no statistically significant difference in genotypic and allelic frequencies of the ACE I/D polymorphism among patients with and without coronary heart disease (DD:ID:II (%), 32:58:11 and 39:44:17, respectively). CONCLUSIONS: ACE gene polymorphism is not a significant parameter to determine coronary heart disease in Turkish type 2 diabetic patients.

Constrictive pericarditis localized to left ventricle presented with left pleural effusion: a case report.

An 18-year old woman presented with progressive dyspnea and cough. Physical examination revealed decreased breath sounds at the left hemithorax and distant heart sounds with no murmurs or rub. Electrocardiogram revealed low voltage. Chest X-ray showed unilateral left-sided pleural effusion with no cardiomegaly. Transthoracic echocardiogram showed thickened pericardium localized throughout the left ventricle impairing the diastolic filling. Doppler waveforms were suggestive of localized constrictive pericarditis. A computerized tomographic scan of the chest confirmed the presence of unilateral pleural effusion with thickened pericardium surrounding the left ventricle. The patient's symptoms and signs were related to localized constrictive pericarditis and improved following surgery.