Effect of Aortic Valve Opening Pattern on Endothelial Function After Continuous-Flow Left Ventricular Assist Device Implantation.

This study aimed to evaluate the effects of aortic valve opening patterns on endothelial functions in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) implantation. This study included 43 patients who underwent CF-LVAD implantation and 35 patients with heart failure reduced ejection fraction (HFrEF; control group). The CF-LVAD group was divided into three subgroups based on aortic valve opening patterns: open with each beat, intermittently opening, and not opening groups. Flow-mediated dilatation (FMD) and pulsatility index (PI) were compared before and 3 months after CF-LVAD implantation. Cardiopulmonary exercise test (CPET) and 6 minute walk test (6-MWT) scores were measured at baseline and follow-up in the CF-LVAD group. The mean FMD and PI of patients in the CF-LVAD group reduced 3 months after implantation. Patients with intermittently opening and not opening aortic valves had worse endothelial function at follow-up. Before and 3 months after implantation FMD% did not significantly differ in patients whose aortic valves were open with each beat (4.72 ± 1.06% vs. 4.67 ± 1.16%, p = 0.135). Pulsatility index changes paralleled FMD changes. Cardiopulmonary exercise test and 6-MWT scores improved after implantation but without significant differences between subgroups. Maintaining normal aortic valve function after CF-LVAD implantation may reduce endothelial dysfunction; however, larger studies are needed for long-term clinical effects.

The outcome of peripartum cardiomyopathy patients-single center experience.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction. BACKGROUND: The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end-points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all-cause mortality. METHOD: Outpatient HF records between 2008 to 2021 were screened. Thirty-seven patients were defined as PPCM. Twenty-five patients had CMR evaluation at the time of diagnosis, and six patients were re-evaluated with CMR. RESULTS: The mean age was 30.5 ± 5.6 years, and the mean LVEF was 28.2% ± 6.7%. In 13(35.7%) patients, LVEF recovered during the follow-up course. The median recovery time was 281(IQR [78-358]) days. LVEF on CMR was 35.3 ± 10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub-endocardial and mid-wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non-compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9 ± 35.4, 86.4 ± 7.5, p = .003; 86.8 ± 34.6, 52.6 ± 7.6, p = .006), respectively. The median follow-up time was 2129 (IQR [911-2634]) days. The primary endpoint-free 1-year survival was 88.9% (event rate 11.1%), and 5-year survival was 75.7% (event rate 24.3%). CONCLUSION: In a retrospective cohort of PPCM patients, 35.7% of patients' LVEF recovered, and the primary end-point of free-5-year survival was 75%. Twenty-five patients were assessed with CMR; three of four met the Petersen CMR-derived LVNC at initial evaluation.

Characteristics and long-term survival of patients with left ventricular non-compaction cardiomyopathy.

AIMS: Left ventricular non-compaction cardiomyopathy (LVNC) is a poorly understood entity resulting in heart failure. Whether it is a distinct form of cardiomyopathy or an anatomical phenotype is a subject of discussion. The current diagnosis is based on morphologic findings by comparing the compacted to non-compacted myocardium. The study aimed to compare demographic and prognostic variables of patients with dilated cardiomyopathy (DCM) and LVNC. Emphasis was given to cardiac magnetic resonance (CMR) imaging analysis. Data on survival were also assessed. METHODS AND RESULTS: We retrospectively evaluated the characteristics and outcomes of 262 non-ischaemic cardiomyopathy patients with LVNC and DCM phenotypes. Petersen's CMR criteria of non-compacted to the compacted myocardial ratio 2.3 were used to diagnose LVNC. The primary endpoint was a composite endpoint of major adverse cardiovascular events comprising cardiovascular-related death, left ventricular assisted device implantation, or heart transplantation. A total of 262 patients with CMR data were included in the study. One hundred fifty-five patients who fulfilled CMR criteria were diagnosed as LVNC. CMR findings revealed that LVNC patients had higher left ventricular end-diastolic (137.2 ± 51.6, 116.8 ± 44.6, P = 0.002) and systolic volume index (98.4 ± 49.5, 85.9 ± 42.7, P = 0.049). Cardiac haemodynamics, cardiac output (5.61 ± 2.03, 4.96 ± 1.83; P = 0.010), stroke volume (73.9 ± 28.8, 65.1 ± 25.1; P = 0.013), and cardiac index (2.85 ± 1.0, 2.37 ± 0.72; P < 0.0001), were higher in LVNC patients. Of all the 249 patients, 102 (40.9%) patients demonstrated late gadolinium enhancement (LGE). According to Petersen's criteria, the Kaplan-Meier survival outcome did not reveal significant differences (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: [0.89-2.63], P = 0.11). The presence or pattern of LGE did not show significant importance for endpoint-free survival. Most of the sub-epicardial LGE pattern was found in LVNC patients (94.4%). When receiver operator characteristics analysis was applied to NC/C ratio to discriminate the primary endpoint, a higher NC/C ratio of 2.57 was associated with adverse events (HR: 1.90, 95% CI: [1.12-3.24], P = 0.016). CONCLUSIONS: Our study questions the criteria being used for the diagnosis of LVNC. Further evaluation of CMR variables and association of these findings with demographic variables and survival is mandatory.

Inferior ST-segment elevation due to metastatic cardiac tumor.

There are numerous causes for ST-segment elevation on ECG, the tumoral invasion of the heart being a rarer one. Because the management will differ one should always keep in mind the presence of such entity. Here we report a case of persistent ST-segment elevation due to a metastatic cardiac tumor.

Effects of Continuous-Flow Left Ventricular Assist Device Therapy on Peripheral Vascular Function.

The peripheral vascular effects of continuous-flow left ventricular assist device (CF-LVAD) implantation are still unclear. The aim of the current study was to determine peripheral vascular function before and after implantation of CF-LVAD in patients with end-stage heart failure (HF), and to compare this data to age- and sex-matched chronic heart failure with reduced ejection fraction (HFrEF) patients. Forty-three consecutive end-stage HF patients (New York Heart Association [NYHA] class III/IV; three women and 40 men; mean age 53 ± 11 years) who planned to receive CF-LVAD implantation comprised the LVAD patient population, and their clinical characteristics, preoperative and third postoperative month peripheral vascular function assessment data including flow-mediated dilation (FMD) and pulsatility index (PI) assessed by ultrasound Doppler in brachial artery were compared to age- and sex-matched chronic, stable HFrEF patients (NYHA class II; five women and 30 men; mean age 51 ± 10 years). After CF-LVAD implantation, median FMD decreased from 5.4 to 3.7% (p < 0.001), and median PI decreased from 6.9 to 1.4 (p < 0.001). In patients with end-stage HF before CF-LVAD implantation, FMD and PI were significantly lower compared to the chronic HFrEF patients (FMD: 5.4% ± 0.9% vs. 7.6% ± 1.1%; p < 0.001, respectively) and (PI: 6.9 ± 1.3 vs. 7.4 ± 1.2; p = 0.023, respectively). The current study revealed impaired peripheral vascular function in the end-stage HF patients compared to stable HFrEF patients, and documented the deterioration of peripheral vascular function after CF-LVAD implantation. These results suggest that impaired peripheral vascular function in the CF-LVAD patients compared to preoperative assessment is a consequence of the nonpulsatile blood flow due to the continuous-flow mechanical support.

Is a drug-challenge test with propafenone adequate to exclude Brugada syndrome?

Brugada syndrome is associated with sudden cardiac death in patients with a structurally normal heart. The electrocardiogram (ECG) pattern of Brugada syndrome is characterised by complete or incomplete right bundle branch block and ST-segment elevation in the right precordial leads. These ECG signs may not always be apparent but can be unmasked with certain anti-arrhythmia agents. We report here a case of a 26-year-old woman without detectable structural heart disease but with a history of syncope, cardiac arrest, intubation and defibrillation for ventricular fibrillation. We performed challenge tests with propafenone and ajmaline. After infusion of propafenone, there were minimal ECG changes which were not diagnostic for Brugada syndrome. One week later the provocation test was repeated with ajmaline. During infusion of ajmaline, prominent J waves and ST-segment elevation appeared in the right precordial leads (V1-3). Premature ventricular complexes were seen on a 12-lead ECG. The patient's ECG showed Brugada type 1 pattern. She received an internal cardioverter/defibrillator and was discharged with a beta-blocker.

Acute myocardial infarction is reflected in salivary matrix metalloproteinase-8 activation level.

BACKGROUND: The aim of this study is to compare salivary and serum biomarker levels and degrees of matrix metalloproteinase (MMP) activation between patients with acute myocardial infarction (AMI) and systemically healthy patients (non-AMI) with similar periodontal conditions. METHODS: A total of 92 patients (47 AMI and 28 non-AMI patients with gingivitis or periodontitis; and 17 systemically and periodontally healthy patients as a control group) were recruited. Clinical periodontal measurements were recorded; stimulated whole saliva and serum samples were collected. AMI patients were clinically examined within 3 to 4 days after admission to the coronary care unit. Saliva samples were analyzed for levels of MMP-8, MMP-7, and tissue inhibitor of matrix metalloproteinase (TIMP)-1. Serums were tested for MMP-8, MMP-9, TIMP-1, and TIMP-2 levels by immunofluorometric assay and enzyme-linked immunosorbent assay. Molecular forms and degree of activation of salivary MMP-8, MMP-9, and MMP-13 were analyzed by computer-scanned immunoblots. RESULTS: Total salivary MMP-8 assessed by immunofluorometric assay method and immunoblot densitometric units was higher in non-AMI than in AMI patients' saliva, but a significantly higher percentage of AMI patients' MMP-8 was activated polymorphonuclear leukocyte (PMN) type (P <0.001) regardless of periodontal diagnosis.Serum MMP-8, MMP-9, and TIMP-1 levels were significantly higher in AMI (for all markers and all comparisons,P <0.05). Characteristic for AMI was dominance of active PMN MMP-8 in saliva [corrected].

Comparison of ischemic side effects of levosimendan and dobutamine with integrated backscatter analysis.

BACKGROUND: Levosimendan improves cardiac contractility without increasing oxygen consumption. However, its effects on ischemia were not supported with the utilization of a noninvasive parameter of myocardial characterization. HYPOTHESIS: The changes observed in integrated backscatter (IBS) may be reflective of change in myocardial ischemia. In this study, the effect of levosimendan on ischemia detected by IBS was evaluated in patients with ischemic heart failure (HF). METHODS: Patients who had LVEF < 40% and NYHA III-IV symptoms of HF were included in this study. Patients were randomized to levosimendan (n = 21), or to dobutamine (n = 25) groups. The cyclic variation of integrated backscatter (CVIBS) was determined as the difference between the maximal and minimal values in a cardiac cycle, average of three consecutive beats. CVIBS was taken from the mid-anteroseptal, mid-inferior, and mid-posterolateral areas of the parasternal short axis images before the drug administration and at the end of the 24-hour infusion period. RESULTS: Baseline characteristics and concomitant medications were similar in both groups. A significant reduction in CVIBS was detected in anteroseptal (7.6 +/- 1.4 dB versus 5.9 +/- 0.8 dB, p = 0.01), inferior wall (7.4 +/- 0.8 dB versus 6.7 +/- 1.5 dB, p = 0.03), and posterolateral wall (9.0 +/- 1.2 dB versus 8.2 +/- 0.6 dB, p = 0.04) after dobutamine administration, while no significant changes were observed in the levosimendan group in all walls. CONCLUSIONS: Unlike dobutamine, levosimendan may not induce myocardial ischemia as shown by CVIBS at commonly used dosages in the setting of decompensated HF without active ischemia.

Comparison of the effects of new and conventional hormone replacement therapies on left ventricular diastolic function in healthy postmenopausal women: a Doppler and ultrasonic backscatter study.

We aimed to compare the effects of new treatment modalities to conventional hormone replacement therapy (HRT) on left ventricular (LV) diastolic function, by means of conventional and tissue Doppler echocardiography and the myocardial integrated backscatter (IBS) in postmenopausal women. One hundred and fifty healthy postmenopausal women were included in this study. Subjects were assigned to one of the five groups receiving 1 year of treatment (estrogen, estrogen plus progesterone, raloxifene, tibolone or placebo). E and A wave velocity, E/A ratio, isovolumic relaxation time (IVRT), deceleration time (DT), peak early (Em) diastolic mitral annular velocity, E/Em ratio, the cyclic variation of integrated backscatter (CVIBS) and the mean value of the IBS signal (MIBS) were determined before and 12 months after therapy. E (76 +/- 10 vs. 98 +/- 8 cm/s, P = 0.0001 and 78 +/- 10 vs. 90 +/- 12 cm/s, P = 0.02, respectively), Em (14.3 +/- 2.4 vs. 16.4 +/- 2.5 cm/s, P = 0.001 and 15.1 +/- 3.4 vs. 16.2 +/- 3.5 cm/s, P = 0.01, respectively), and E/A ratio (1.15 +/- 0.3 vs. 1.42 +/- 0.4, P = 0.0001 and 1.0 +/- 0.2 vs. 1.22 +/- 0.2, P = 0.01, respectively) were increased significantly compared to pretreatment in both estrogen and raloxifene groups while DT, A, E/Em, and IVRT were significantly decreased. A significant increase in CVIBS and decrease in MIBS were detected 12 months after estrogen and raloxifene administration while no significant changes were observed in other groups. Changes in the MIBS and CVIBS were found to be independently associated with the observed changes in the diastolic function indexes during therapy. Both estrogen and raloxifene regimens may improve LV diastolic functions in healthy postmenopausal women. This improvement may be a result of direct cardiac effects on LV myocardium.

Effects of levosimendan on left atrial functions in patients with ischemic heart failure.

BACKGROUND: With further progression of left ventricular (LV) dysfunction, the left atrial (LA) contribution to LV filling gradually decreases, and LA dysfunction deteriorates the decreased LV filling in patients with heart failure (HF). HYPOTHESIS: This study sought to investigate the effects of levosimendan on LA function in patients with HF. METHODS: A total of 60 patients having acute decompensated HF with ischemic cardiomyopathy and LV ejection fraction (LVEF) < 40% were included in the study. Patients were randomized to levosimendan (n = 30) or to dobutamine (n = 30). Before and 24 h after treatment, LVEF, mitral inflow peak E and A wave velocity, E/A ratio, mitral lateral annulus peak Em wave velocity, E/Em ratio, LA volumes, and from the LA volumes the active emptying fraction (AEF), passive emptying fraction (PEF), and reservoir fraction (RF) were measured. RESULTS: All LA volumes were significantly reduced after levosimendan administration, but in the dobutamine group only minimal volume (Vmin) was reduced. Although AEF increased in both groups, the improvement of AEF was greater in the levosimendan group than in the dobutamine group (14% +/- 9% versus 2% +/- 1%, p = 0.001). The PEF (12% +/- 8% versus 21% +/- 6%, p = 0.04) and RF (23% +/- 4% versus 38% +/- 3%, p = 0.001) significantly increased after levosimendan administration, whereas these parameters did not change after dobutamine. In patients receiving levosimendan, there was a significant, positive correlation between PEF and Em (r = 0.475, p = 0.008), and there were significant negative correlations between PEF and E/Em (r = - 0.491, p = 0.006), and AEF and E/Em (r = - 0.654, p = 0.001). CONCLUSIONS: Left atrial functions respond better to levosimendan than to dobutamine in decompensated HF.

Circadian and infradian rhythms of vasovagal syncope in young and middle-aged subjects.

BACKGROUND: The most cardiovascular physiological and pathophysiological events show a circadian rhythm. It is thought that the autonomic nervous system and biologic factors play a key role in the pathogenesis of vasovagal syncope (VVS). In this study, we investigated the circadian and infradian variation of VVS. METHODS: A prospective consecutive series of 246 patients (142 women; mean age 36+/-7 years) with recurrent syncope and with a positive head-up tilt testing (HUT) were included in this study. The daily and weekly distributions of the syncopal episodes were investigated. The assessments of episodes were done according to the days of the week and three time periods of the day (6 a.m.-12 noon, 12 noon-6 p.m., 6 pm-12 midnight). RESULTS: According to the results of HUT, 76 patients (31%) had cardioinhibitory, 62 patients (25%) had vasodepressor, and 108 patients (44%) had mixed type of VVS. During the initial passive phase, 40% of patients (99/246) showed positive response. Time to syncope was 20+/-2 minutes during HUT. The mean number of syncopal episodes was 4+/-2/years. In all, 1,070 episodes were evaluated. The distribution of the episodes in 6-hour intervals was significantly different from uniform occurrence (38%, 33%, and 29%, respectively) (P=0.02). The frequency of episodes was higher in the morning (P=0.045) and in the middle of the week (P=0.046). A significant difference was found between week and weekend days in terms of the frequency of episodes (75.5% vs 24.5%, P=0.01). CONCLUSION: VVS may show a circadian and infradian rhythm.

[The determination of the factors impacting on in-hospital mortality in patients with acute heart failure in a tertiary referral center]. / Tersiyer bir merkezde akut kalp yetersizlikli hastalarda hastane içi mortaliteye etkili faktörlerin belirlenmesi.

OBJECTIVE: Despite impressive advances in therapeutics in the last years, acute heart failure (AHF) remains a major cause of cardiovascular morbidity and mortality. Patients hospitalized because of heart failure (HF), irrespective of left ventricular systolic function, represent a high-risk population with limited short-term prognosis. A substantial component of HF-related mortality occurs during a hospital stay. In this study, we aimed to determine the factors impacting on in-hospital mortality in patients with AHF. METHODS: During a 15-month period (December 2005-March 2007), 85 consecutive patients with (mean age: 64+/-8 years, male: 54%) an episode of AHF were included in this study. The effect of demographic, clinical, electrocardiographic, and echocardiographic characteristics, laboratory findings on in-hospital mortality were evaluated retrospectively. RESULTS: Of 85 patients 24.7% of patients had new-onset HF. Coronary artery disease (61%) was the most common underlying disease. The 44.7% of patients had hypertension, 37.6% had diabetes mellitus, 21% had chronic renal failure and 16.4% had chronic obstructive pulmonary disease. Left ventricular ejection fraction was 35+/-7%. In-hospital mortality rate was found as 11.7% (10 patients). The major cause of mortality was the progression of HF to cardiogenic shock in 60% of deaths. In comparison with surviving patients in terms of the clinical, demographic, electrocardiographic, and laboratory characteristics and left and right ventricular functions, patients died during hospitalization had higher blood urea nitrogen (45+/-20 mg/dl vs. 36+/-12 mg/dl, p=0.04), higher creatinine level (2.2+/-0.8 mg/dl vs. 1.1+/-0.5 mg/dl, p=0.001), and wider QRS duration (130+/-13 ms vs. 116+/-18 ms, p=0.04) whereas they had lower plasma sodium level (128+/-5 mmol/l vs. 135+/-9 mmol/l, p=0.02) and systolic blood pressure (p=0.01). Logistic regression analysis revealed that plasma creatinine level (OR 1.5, 95% CI 1.2 to 2.1, p=0.01), blood urea nitrogen (OR 2.1, 95% CI 1.8 to 3.1, p=0.001), plasma sodium level (OR 1.3, 95% CI 1.1 to 1.7, p=0.02), and systolic blood pressure (OR 2.2, 95% CI 1.9 to 2.8, p=0.01) were the independent predictors of in-hospital mortality. CONCLUSION: In-hospital mortality increases in patients who had lower systolic blood pressure, lower plasma sodium level, and renal dysfunction on admission.

Apical hypertrophic cardiomyopathy might lead to misdiagnosis of ischaemic heart disease.

PURPOSE: In this study, demographic, clinic, electrocardiographic and angiographic properties of patients, on whom coronary angiography was performed with the pre-diagnosis of coronary artery disease (CAD) and whose ventriculography demonstrated typical apical hypertrophic cardiomyopathy (AHCM), were investigated. METHODS: Seventeen patients (mean age 58 +/- 10 years, 10 male) with CAD pre-diagnosis, on whom coronary angiography was performed and had typical spade-like appearance on left ventriculography, were included in the study between January 2000 and May 2005. RESULTS: As risk factor for CAD, 8 (47%) patients had hypertension, 8 (47%) patients had dyslipidaemia, 2 (11%) patients had type 2 diabetes mellitus, 13 (77%) patients had a history of smoking, and 2 (11%) patients had family history. Seven (42%) patients presented unstable angina pectoris, 8 (47%) patients presented stable angina pectoris and 2 (11%) patients were asymptomatic. On coronary angiography, it was determined that 10 (58%) patients had normal coronary arteries, 3 (17%) patients had non-significant stenosis and 4 (25%) patients had myocardial bridging. Five (30%) patients revealed mid-ventricular obstruction and intraventricular gradient was 25 +/- 5 mmHg by the catheterization. All patients showed ''giant'' negative (> or = 10 mm) T waves in the precordial leads, whereas 2 patients had atrial fibrillation. Maximum wall thickness was measured as 18 +/- 4 mm in the apical region by transthoracic echocardiography. One patient (5%) who had mid-ventricular obstruction developed atrial fibrillation during 2 years follow-up, though any other events did not occur during hospitalization or follow-up period. CONCLUSIONS: Physicians caring for patients with chest pain should consider AHCM in their differential diagnosis in case of a patient with chest pain and electrocardiographic changes suggestive of CAD.

The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study.

BACKGROUND: Recurrent vasovagal syncope (VVS) can be a severely disabling disorder that may lead to an important deterioration of quality of life because of the severity and recurrence of episodes. This study sought to investigate the effectiveness of repeated orthostatic self-training in preventing syncope in patients with recurrent VVS. METHODS: Eighty-two consecutive patients (mean age 41 +/- 4 years, 37 males) with recurrent VVS episodes and positive head-up tilt testing (HUT) were enrolled in this study. The patients were then randomized (1:1) to conventional therapy or conventional therapy plus additional tilt training sessions. The patients were followed for spontaneous syncope for one year. Primary end-points were the recurrence of syncope, the number of episodes, and the interval of time to the first recurrence. RESULTS: There were no significant differences of baseline clinical characteristics and parameters of HUT between the tilt training and control groups. The patients had 4 +/- 2/year syncopal episodes prior to the HUT. The mean follow-up after randomization was 12 +/- 2 months. Spontaneous syncope recurrence during follow-up was 56% (23 patients) versus 37% (15 patients) in the control and tilt training groups, respectively (P = 0.1). Time to first recurrence was also similar in both groups (70 +/- 20 days vs 50 +/- 15 days, P = 0.09). The frequency of recurrent syncopes was similar in all types of VVSs while the rate of episodes was significantly higher in control group in patients with vasodepressor type during follow-up period (32% vs 10%, P = 0.04). The mean number of recurrent syncope episodes was also similar in both groups (3 +/- 1 vs 2 +/- 1, P = 0.4). CONCLUSIONS: Tilt training was unable to influence the spontaneous syncope recurrence for recurrent VVS except for vasodepressor type.

Effect of levosimendan on E/E' ratio in patients with ischemic heart failure.

BACKGROUND: Levosimendan is a novel positive inotropic calcium sensitizer agent used in acute heart failure. In acute heart failure, it improves hemodynamic parameters more favorably than the conventional positive inotropes. In this study, the effect levosimendan on E/E' ratio as a non-invasive indicator of LV filling pressure was evaluated compared to dobutamine in a prospective, randomized, patient-blind manner. METHODS: Patients with an LVEF < 40% admitting with acute heart failure attack with ischemic origin were included to this study. Patients were randomized to levosimendan (n=30, mean age: 64+/-10 years, 63% male) or dobutamine (n=32, mean age: 66+/-8 years, 54% male) groups. The ratio of the peak E wave velocity taken from mitral inflow with PW Doppler to the peak E' wave velocity taken from mitral lateral annulus with tissue Doppler was determined. Pre-treatment and 24-hour after the treatment E/E' ratios were calculated and then compared in both groups. RESULTS: Age, gender, concomitant medications were similar in both groups (p>0.05). There was no difference for pre-treatment baseline E/E' ratios between levosimendan and dobutamine groups (15.7+/-4.0 vs 15.2+/-7.5 respectively, p=0.1). There were significant reductions in post-treatment E/E' ratios in levosimendan (15.7+/-4.0 vs 9.3+/-2.8, p=0.01) and dobutamine groups (15.2+/-7.5 vs 12.9+/-5.6, p=0.04). However, the reduction in levosimendan group was greater compared to dobutamine group (p=0.01). CONCLUSIONS: Levosimendan causes a greater reduction of E/E' ratio compared to dobutamine in acute systolic left heart failure. This may explain the more favorable hemodynamic effects of levosimendan when compared to conventional positive inotropics in patients with systolic left heart failure.

High-sensitivity C-reactive protein may be an indicator of the development of atherosclerosis in myocardial bridging.

BACKGROUND: Inflammation is one of the key mechanism in the development and progression of coronary artery disease. Myocardial bridging (MB) increases the tendency for development of atherosclerosis. The role of inflammation on the development of atherosclerosis in the MB is not clear. In this study, we investigated the existence of inflammation in the patients who have atherosclerotic plaque in the bridged segment. METHODS: This study included 40 patients (group I) presented with stable angina pectoris and detected MB in LAD on coronary angiography and 30 control subjects (group II) with normal coronary angiogram. Patients in group I were divided into two subgroups based on the findings on intravascular ultrasound (IVUS): group IA included 25 patients without atherosclerotic lesion in any coronary artery and group IB included 15 patients with atherosclerotic lesion in addition to MB in bridged segment of LAD. High-sensitivity C-reactive protein (hs-CRP) levels were compared between group I and II and group IA and IB. RESULTS: IVUS showed an atherosclerotic involvement with the proximal segment of MB in 15 patients (=group IB). No plaques were seen in other coronary arteries, in distal of MB or in the bridged segment. With regards to the level of hs-CRP, while no difference was established between group I and group II (1.7+/-0.4 mg/L vs 1.9+/-0.6 mg/L, p>0.05), hs-CRP was significantly higher in group IB than in group IA (3.2+/-0.3 mg/L vs 1.5+/-0.2 mg/L, p=0.001) and control group (3.2+/-0.3 mg/L vs 1.9+/-0.6 mg/L, p=0.03). A significant positive correlation was detected between the hs-CRP and the percentage of atherosclerotic stenosis on IVUS in group IB (R=0.639, p=0.01). CONCLUSIONS: These results indicate the presence of a low grade inflammation in patients with atherosclerotic lesion in bridged segment.

Objective ischemic evidence in patients with myocardial bridging: ultrasonic tissue characterization with dobutamine stress integrated backscatter.

BACKGROUND: In this study, we investigated the sensitivities of dobutamine stress echocardiography (DSE) and integrated backscatter (IBS) in detecting ischemia in patients with symptomatic myocardial bridging (MB). METHODS: Fourteen patients given the diagnosis of MB in the left anterior descending coronary artery as shown by coronary angiography were enrolled. All patients underwent DSE and stress IBS. The cyclic variation of IBS (CVIBS) was taken from the midanteroseptal, midinferior, and midposterolateral areas of the parasternal short-axis images at rest, low dose, peak dose, and recovery. The low-dose, peak-dose, and recovery CVIBS data were compared with baseline values. RESULTS: At peak dose, hypokinesia was observed in the left anterior descending coronary artery region in two patients (14%). A significant reduction in CVIBS was detected only when compared with the baseline at peak dose in the anteroseptal wall (8.4 +/- 1.3 vs 5.9 +/- 0.8, P = .003). A significant negative correlation was found between the CVIBS and the systolic narrowing percentage (R = -0.856, P = .001) and the length of MB (R = -0.576, P = .01) in the anteroseptal wall at peak dose. CONCLUSIONS: Whereas DSE is not sufficiently sensitive in the detection of ischemia in patients with symptomatic MB, the reduction in CVIBS during DSE may be an objective sign of ischemia.

Myocardial bridge: a bridge to atherosclerosis.

OBJECTIVE: Myocardial bridge (MB) is a congenital anomaly characterized by narrowing during systole of some of the epicardial coronary arterial segments running in the myocardium. Although, it is considered as a benign anomaly, it may lead to such complications as acute myocardial infarction, ventricular tachycardia, syncope, atrioventricular block and sudden cardiac death. In this study, we aimed to investigate demographic, clinical and angiographic characteristics of the patients with MB found on coronary angiography. METHODS: The present study included 71 patients with MB found on coronary angiographies performed in our institution between January 1999 and September 2003. Based on the findings on angiography, the patients were subdivided into group A (n=41) and group B (n=30). The patients in the group A had no atherosclerotic lesion and the patients in the group B had coronary artery disease in addition to MB. Angiographic, demographic and clinical characteristics of both groups were compared. RESULTS: There were no differences between two groups in distribution of gender and risk factors of coronary artery disease whereas mean age of the patients in the group A was lower (47+/-5 years vs 55+/-11 years, p=0.01). Frequency of two or more risk factors for coronary artery disease in a particular patient was significantly higher in the group B (55% vs 30%, p=0.03). Myocardial bridge was located at proximal or mid segments of left anterior descending artery (LAD) in 40 patients whereas its presence in both LAD and right coronary artery was found only in one patient in group A. Mean bridging percent was 43+/-27% in group A. Localization of MB was LAD in 29 patients of group B. One patient with severe aortic valve stenosis in this group had MB at first septal branch. Mean bridging percent was 70+/-25% in group B, which was significantly higher than in group A (p<0.05). Atherosclerotic narrowing developed in only LAD in 14 patients, LAD and other vessels in 7 patients and in the vessels without MB in 9 patients. In patients with MB in LAD atherosclerotic narrowing of vessel developed proximally to the MB. Clinically, stable angina pectoris was seen more frequently in group A than group B (70% vs 35%, p=0.01), whereas the frequency of acute coronary syndrome was higher in group B (65% vs 30%, p=0.04). In regard to therapeutic approach, more patients in the group A received medical management (80% vs 50%, p=0.01), while more patients in the group B underwent surgical and percutaneous interventions (50% vs 18%, p=0.04). CONCLUSION: Myocardial bridge probability should be considered in young patients presenting with angina or if the same symptoms are persistent in the patients without more than one risk factor for coronary artery disease. Myocardial bridge may initiate the development of atherosclerotic lesion or may facilitate progression of atherosclerosis in the proximal segment of the vessel. The risk of acute coronary syndrome rises when atherosclerosis is superimposed on MB. Myocardial bridge should be considered in the young patients, presenting with angina or its equivalents without atherosclerotic lesions on coronary angiography.

Primary cardiac amyloidosis mimicking interstitial lung disease and bleeding diathesis: a case report.

Primary amyloidosis is a rare systemic disease due to various organ involvements that can lead to atypical clinical findings. In this article, we discuss a case of primary cardiac amyloidosis in a patient presenting with bleeding eyelids and interstitial lung disease.

Impaired endothelial function in patients with myocardial bridge.

OBJECTIVE: The relationship between myocardial bridging (MB) and ischemic heart disease is still controversial. In this study, we aimed to evaluate the existing atherosclerosis and noninvasive endothelial function of brachial artery in patients with MB. METHODS: The present study included 50 patients (group I) who had MB in left anterior descending (LAD) on coronary angiography. All of the coronary artery segments were evaluated by intravascular ultrasound (IVUS). Endothelial function was assessed with measurement of flow-mediated dilatation (FMD) and nitrate-dependent dilatation in the brachial artery. The study also included 30 healthy control subjects (group II). Patients in the group I were further subdivided into two subgroups based on the findings on IVUS: group IA included 20 patients without atherosclerotic lesions and group IB included 30 patients with atherosclerotic coronary artery disease in addition to MB. RESULTS: FMD values were found to be significantly lower in the patients with MB (group I) than in the control (6.4 +/- 3% vs 11 +/- 4%, P <0.001). In regard to FMD values in subgroups, FMD was 7 +/- 2% in the group IA and 5.8 +/- 1% in the group IB (P = 0.023). On IVUS, atherosclerotic plaque was found proximal to the bridge in the same coronary artery segment in addition to MB in 75% of the patients in group I (group IB). No atherosclerotic plaque was found in within or distal segments of MB. CONCLUSION: Endothelial function is impaired in patients with MB and there is an increased tendency for atherosclerosis proximal to the bridge in the patients with MB. Endothelial dysfunction is more severe in the patients with atherosclerosis proximal to the bridge.