Comparison of DDD versus VVIR pacing modes in elderly patients with atrioventricular block.

OBJECTIVES: Dual-chamber pacing is believed to have an advantage over single-chamber ventricular pacing. The aim of this study was to determine whether elderly patients who have implanted pacemakers for complete atrioventricular block gain significant benefits from dual-chamber (DDD) pacemakers compared with single chamber ventricular (VVIR) pacemakers. STUDY DESIGN: This study was designed as a randomized, two-period crossover study-each pacing mode was maintained for 1 month. Thirty patients (16 men, mean age 68.87 ± 6.89 years) with implanted DDD pacemakers were submitted to a standard protocol, which included an interview, pacemaker syndrome assessment, health related quality of life (HRQoL) questionnaires assessed by an SF-36 test, 6-minute walk test (6MWT), and transthoracic echocardiographic examinations. All of these parameters were obtained on both DDD and VVIR mode pacing. Paired data were compared. RESULTS: HRQoL scores were similar, and 6MWT results did not differ between the two groups. VVIR pacing elicited significant enlargement of the left atrium and impaired left ventricular diastolic functions as compared with DDD pacing. Two patients reported subclinical pacemaker syndrome, but this was not statistically significant. CONCLUSION: Our study revealed that in active elderly patients with complete heart block, DDD pacing and VVIR pacing yielded similar improvements in QoL and exercise performance. However, after a short follow-up period, we noted that VVIR pacing caused significant left atrial enlargement and impaired left ventricular diastolic functions.

Echocardiographic Predictors of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhythm.

Introduction: Rheumatic mitral stenosis (RMS) increases the risk of both atrial fibrillation (AF) and thromboembolism. Methods: Patients with mitral stenosis and normal sinus rhythm were enrolled in the study prospectively.The present study was designed to study whether echocardiographic evaluation in patients with mitral stenosis and normal sinus rhythm could predict the occurrence of symptomatic AF . RESULTS: Sixty-two patients (51 females) with mitral stenosis and normal sinus rhythm were included in the study. Seven patients (11.3%) developed symptomatic AF and the remaining 55 were free of AF during a followed-up of 22±5 months. The following echocardiographic parameters were significantly increased and predicted the development of AF; left atrial (LA) mediolateral diameter (5.5 ± 0.5 cm vs 4.7 ± 0.7 cm), right atrial mediolateral diameter (4,7 ± 1.0 cm vs 3.6 ± 1.3 cm), LA area in the apical two chamber view ( 31 ± 3.2 cm2 vs 25 ± 5.8 cm2), right atrial volume (52 ± 22 cm3 vs 34 ± 19 cm3), and interatrial conduction time (IACT) (142 ± 22 msec vs 115 ± 16 msec). Conclusions: This study revealed that echocardiography can be used to predict symptomatic AF in patients with RMS and sinus rhythm.

Transient cortical blindness after cardiac catheterization with iobitridol.

The occurrence rate of transient cortical blindness after contrast media exposure has been reported to be as high as 1% to 4% after cerebral or vertebral angiography, but such blindness has been described in only a few cases of coronary angiography with modern, non-ionic, low-osmolality radio-contrast agents. In this study, we present a case of abrupt cortical blindness after exposure to contrast media during diagnostic coronary angiography; to our knowledge, this is the 1st report in the medical literature that describes transient cortical blindness after iobitridol use.

The time interval from the initiation of the P-wave to the start of left atrial appendage ejection flow: does it reflect interatrial conduction time?

UNLABELLED: Recurrence of atrial fibrillation is more common in patients with atrial conduction delay. In the present study, we evaluated whether findings obtained from transesophageal echocardiography (TEE), a semi-invasive method, correlate with those from an invasive method, electrophysiologic study (EPS), in measuring interatrial conduction time. METHODS AND RESULTS: We compared two methods of calculating interatrial conduction time in a group of 33 patients. The origin of the P-wave on the surface electrocardiogram (ECG) was taken as the onset of atrial activation. The time interval from this point to the commencement of the left atrial appendage ejection flow (P-LAA) was measured by TEE. Meanwhile, simultaneous recordings of the left atrial appendage were obtained with a catheter positioned in the LAA, and an invasive interatrial conduction time was measured from the origin of the surface's earliest P-wave (I-IACT). The mean I-IACT (46.27 +/- 13.25 ms) correlated strongly with the mean P-LAA (49.91 +/- 12.72 ms; r = 0.839, P < 0.0001). CONCLUSION: The interatrial conduction time can be estimated with a relatively noninvasive method using P-LAA measurements. This technique can be applied widely in predicting AF recurrence, and appropriate therapy may be applied.

Factors influencing emergency department arrival time and in-hospital management of patients with acute myocardial infarction.

Reperfusion of the infarct-related artery in the very first hour ("golden hour") of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylül University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients' arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, Ill), version 11.0, was used for all statistical analyses. The mean "symptom onset-hospital arrival time" was 188+/-325 min for the entire study group. The median delay was 110 min (approximately 2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245-/+363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the "golden hour" because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups.

Infection with Chlamydia pneumoniae but not Helicobacter pylori is related to elevated apolipoprotein B levels.

OBJECTIVE: Results of many studies show that apolipoprotein B (apo B) is a better marker of risk of vascular disease than other lipid markers including LDL and HDL-cholesterol and triglycerides. We investigated the association between two infectious agents: C. pneumoniae and H. pylori, known to have an atherogenic effect, and apo B, to evaluate the effects of chronic infections on apo B levels. METHODS AND RESULTS: The study group consisted of 257 patients in whom diagnostic coronary angiography was performed. C. pneumoniae IgG and IgM and H. pylori IgG and IgA antibodies were measured by enzyme-linked immunosorbent assay and apo B levels were measured by the nephelometry method. Established risk factors of atherosclerosis were recorded. Of 257 patients recruited, 104 had normal vessels, 88 had 3 or more vessels obstructed and 65 had ectatic vessels without atherosclerosis. Mean apo B concentration was significantly higher in C. pneumoniae IgG and IgM positive healthy subjects compared with C. pneumoniae negatives (0.954 vs. 0.722 and 0.973 vs. 0.851, p < 0.001 and p = 0.007, respectively). Apo B levels were significantly higher in severe atherosclerotic patients (0.985 +/- 0.234 g/l) compared with control subjects (0.892 +/- 0.244 g/l) (p = 0.008), but the difference was not significant in ectatic subjects (0.946 +/- 0.272 g/l) when compared with controls (p = 0.18). Apo B levels were higher but not statistically significant in H. pylori antibody positive cases when compared with negatives. CONCLUSIONS: Apo B levels increased with C. pneumoniae infection. This finding supports the hypothesis that lipid profiles change to atherogenic lipid profile in chronic infections.

Tilt training for recurrent neurocardiogenic syncope: effectiveness, patient compliance, and scheduling the frequency of training sessions.

Unsatisfactory results obtained with medical therapy and dual-chamber pacing for prevention of recurrent neurocardiogenic syncope necessitated the development of new treatment modalities. Tilt-training, a novel treatment for recurrent neurocardiogenic syncope based on exercise sessions with prolonged upright posture (either on a tilt-table or standing on foot against a wall), was shown to be effective in preventing the recurrence of neurocardiogenic syncope. The purpose of this study was to demonstrate the long-term beneficial effects of a transient tilt training program lasting 2 months. Thirty-two patients with recurrent neurocardiogenic syncope (mean number of syncope episodes in the last 6 months was 3.4 +/- 2.3) constituted the study group. All of the patients were tilt test positive. The patients were taught a tilt training program with 2 phases (in-hospital training with repeated tilt procedures until 3 consecutive negative results were obtained and home exercises with standing against a wall) and home exercises lasted a maximum of 2 months. After this training program, the patients received no treatment and were followed for the recurrence of syncope. At the end of the follow-up period (376 +/- 45 days), 81% of the patients were free of recurrent syncope. This study revealed that similar successful results can also be obtained with a transient tilt training program as a first line treatment strategy. Less interference with the daily activities of the patients is the major advantage of this strategy. The ease of performance and high effectiveness rate will most likely result in more frequent utilization of this treatment modality.

Plasma interleukin-6 levels are increased in coronary artery ectasia.

OBJECTIVE: Recent studies have suggested a cytokine-induced tissue inflammation in the pathogenesis of abdominal aortic aneurysms and it has been documented that circulating interleukin-6 (IL-6) levels in these patients are increased. The aim of this study was to investigate whether a similar association also exists for patients with coronary ectasia, which may also be regarded as an abnormal dilatation of the arterial system. METHODS AND RESULTS: The study group was composed of 43 patients with coronary ectasia and 48 patients with normal coronary arteries constituted the control group. Coronary diameters were measured by quantitative angiography. A coronary diameter index was defined for each segment as the coronary diameter divided by the body surface area (BSA). A coronary segment with a diameter index of more than 1.5 fold of the control group was defined as ectatic. Baseline characteristics of the two groups were similar. Serum IL-6 levels were significantly higher in patients with coronary ectasia (5.18 +/- 2.04 pg/ml vs. 4.13 +/- 0.5 pg/ml, p = 0.002). There was no significant correlation with the maximal diameter of the most dilated coronary segment and IL-6 levels in patients with coronary ectasia (r = 0.10, p = 0.50). CONCLUSIONS: Results of this study have demonstrated increased levels of circulating IL-6 in patients with coronary ectasia which might indicate a possible role of inflammatory processes. Absence of a significant correlation between the dimensions of the ectatic segments and IL-6 levels might be due to the narrower range of the diameters of the coronary arteries compared with the abdominal aorta.

Efficacy of propafenone for maintaining sinus rhythm in patients with recent onset or persistent atrial fibrillation after conversion: a randomized, placebo-controlled study.

OBJECTIVE: The aim of this study was to investigate the efficacy and safety of propafenone in the prevention of atrial fibrillation (AF) relapse after restoration of sinus rhythm. METHODS: This study consisted of 110 consecutive patients with recent onset and persistent AF. After restoration of sinus rhythm, patients were randomized to propafenone (n: 58, age: 60 +/- 12 years) or placebo (n: 52, age: 62 +/- 10 years).There were 11 withdrawals (7 in the propafenone and 4 in the placebo group) during follow-up. Follow-up evalutations were conducted at the first, 3rd and then at an interval of three months during 15 months. The clinical characteristics in both groups were comparable. The AF relapse was analysed by the Kaplan-Meier method. RESULTS: At 15-month follow-up, AF relapsed in 20 (39%) and 31 (65%) patients in the propafenone and placebo groups, respectively (p = 0.015). In subgroup analysis, AF recurrence was significantly lower in the propafenone group than in the placebo group only in the recent onset AF patients with spontaneous conversion (21% vs. 61%, p = 0.01). However, the AF relapse rates were similar in patients with persistent AF and with recent AF who converted to sinus rhythm pharmacologically or electrically in the propafenone and placebo groups. Four patients on propafenone and one on placebo had adverse effects necessitating discontinuation of the drug (p = 0.36). CONCLUSION: At 15 months, propafenone seems to be superior to placebo for maintaining sinus rhythm in patients with recent onset or peristent AF. This superiority originates mainly from patients with recent onset AF in whom sinus rhythm occurred spontaneously. Its adverse effects are similar to placebo.

Predictors of exercise induced myocardial ischemia in patients with isolated coronary artery ectasia.

The aim of this study was to investigate the angiographic predictors of exercise induced ischemia in patients with isolated coronary ectasia. We have prospectively analysed coronary angiograms of 1521 consecutive patients undergoing cardiac catheterisation. The overall incidence of coronary ectasia was 6.7% (102 patients). Forty-six patients (3%) with non-obstructive, diffuse or segmental coronary ectasia (i.e. isolated coronary ectasia) constituted the main study group. Coronary angiograms were reviewed for stigmata of an impaired coronary blood flow such as 'slow flow', 'segmental backflow phenomenon' and stasis. 'Slow flow' was quantified with frame counting. An ectasia-jeopardy score was also described in order to assess the effect of the extent of coronary ectasia on exercise induced ischemia. Exercise induced ischemia was observed in 24 patients (52%). Exercise test was abnormal in 70% of the patients with diffuse ectasia and 26% of patients with segmental ectasia (p = 0.003). The frame count of the arteries of the study group was higher than the control group but the correlation between the frame count of the ectatic vessels and exercise induced ischemia was not significant. Stasis of the dye also did not correlate with ischemia. There was a significant correlation between exercise induced ischemia and backflow phenomenon in left anterior descending artery (LAD) (r = 0.56, p = 0.0001). Exercise induced ischemia was best correlated with the ectasia-jeopardy score (r = 0.77, p = 0.0001) and a score of > or =4 identified the patients at risk with 90% sensitivity and 80% specificity. In conclusion, the extent of the ectasia within the coronary tree, diffuse ectasia and backflow-phenomenon in LAD were identified as the most important predictors of exercise induced ischemia.

Diagnostic value of D-dimer and antithrombin-III levels in predicting prosthetic heart valve thrombosis.

The aim of this prospective study was to investigate the diagnostic value of plasma D-dimer levels and antithrombin-III activity in predicting prosthetic valve thrombus. The study group comprised 97 consecutive patients with prosthetic heart valves (59 with mitral, 21 with aortic, and 17 with both mitral and aortic prostheses) and 35 healthy control subjects. Six patients presented with symptoms of obstruction; the remaining 91 were asymptomatic. Patients were evaluated by both transthoracic and transesophageal echocardiography. Asymptomatic nonobstructive thrombus was detected in 13 patients (13%), whereas obstructive thrombus was demonstrated in all symptomatic patients. Plasma antithrombin-III levels of patients with prosthetic valve thrombi were slightly lower than those of patients without thrombus and of the control group, but the difference was not statistically significant. However, significantly higher plasma D-dimer levels were observed in patients with prosthetic valve thrombi, compared with patients without thrombus and the control group (735 +/- 633 microg/L, 372 +/- 342 microg/L, and 228 +/- 219 microg/L, respectively). Valve thrombus, the prosthetic heart valve itself, and INR levels were identified as major determinants of plasma D-dimer levels. A plasma D-dimer level of >445 microg/L predicted the presence of a prosthetic valve thrombus with 57.8% sensitivity and 83.3% specificity (positive predictive value, 47.8%; negative predictive value, 87.8%). Current data suggest that increased plasma D-dimer levels can be clinically helpful in predicting the presence of prosthetic valve thrombus. Plasma antithrombin-III activity does not seem to have a diagnostic value in predicting prosthetic valve thrombi.

Does impaired left ventricular relaxation affect P wave dispersion in patients with hypertension?

OBJECTIVE: P wave dispersion (PD) is considered to reflect the heterogeneous conduction in atria. We investigated whether there was a correlation between the left ventricular (LV) relaxation and PD. METHOD AND RESULTS: Fifty-three hypertensive patients < or =60 years old were divided into two groups: Group A, 27 patients, aged 54+/-5 years with the impaired LV relaxation and Group B, 26 patients, aged 51+/-8 years with normal LV relaxation. The P wave durations were measured in all 12 leads of ECG and PD was defined as the difference between maximum and minimum P wave duration (Pmax-Pmin). Mitral inflow velocities (E and A), E deceleration time (DT), isovolumic relaxation time (IVRT), left atrial and ventricular diameters, and wall thickness of LV were obtained by echocardiography. Clinical characteristics of both groups were comparable. The wall thickness of LV, Pmax, and left atrial dimension were not different in both groups. A velocity was higher (P<0.001), but E velocity (P=0.03) and E/A ratio (P<0.001) were lower in group A than in group B. IVRT and DT were also significantly longer in group A. PD was significantly higher in group A compared to group B (51+/-9 vs 41+/-11 ms, P=0.01). This difference resulted from the Pmin (61+/-10 vs 67+/-9 ms, P=0.03, respectively). Multivariate analysis revealed a significant correlation between PD and A velocity (r=0.46, P=0.01), E/A ratio (r=-0.53, P=0.001), DT (r=0.65, P<0.001), and IVRT (r=0.73, P<0.001). CONCLUSION: This study suggests that impaired LV relaxation contributes to the heterogeneous atrial conduction in hypertensive patients.

Gastroduodenal Helicobacter pylori infection diagnosed by Helicobacter pylori stool antigen is related to atherosclerosis.

OBJECTIVE: The causative relation between Helicobacter pylori (H. pylori) and atherosclerosis has been determined as seropositivity or determination of H. pylori from atherome plaques by molecular methods. The site of entrance and the reservoir of the bacteria in the body is still a subject of discussion. In this study Helicobacter pylori stool antigen (HpSA) which shows gastrointestinal system colonization and infection with high specificity and sensitivity was determined in atherosclerotic, ectatic and angiographically normal groups. METHODS AND RESULTS: A total of 62 patients was categorized according to diagnostic coronary angiography as 12 had normal coronary arteries, eight had one, 18 had two, and 12 had three atherosclerotic coronary arteries. Twelve patients had ectatic vessels. There were 27 (44%) HpSA positive and 35 (56%) HpSA negative patients. There was a statistically significant relation between HpSA positivity and the degree of vessel involvement in coronary artery disease (CAD) patients, essentially between the group with three vessels (83%) obstructed and the normal group (25%). Ectatic vessel group had a higher incidence (50%) of HpSA positivity compared to the control group but not enough for statistical significance. CONCLUSIONS: The results indicate that gastrointestinal system H. pylori colonization increases the risk of atherosclerosis. We may speculate that the reservoir and spread of H. pylori is via gastrointestinal tract. Studies may be performed to detect whether gastrointestinal tract H. pylori infection treatment will decrease the risk of coronary artery damage caused by H. pylori.

Use of tissue Doppler echocardiography in early detection of left ventricular systolic dysfunction in patients with mitral regurgitation.

OBJECTIVE: Left ventricular ejection fraction (EF) and left ventricular (LV) end-systolic diameter measurements are the most widely accepted and utilized methods to demonstrate LV dysfunction in patients with mitral regurgitation (MR). However, these parameters still have many drawbacks in predicting early LV dysfunction. This study investigates the clinical usefulness of tissue Doppler echocardiography technique in detecting early disturbance of myocardial contractility in asymptomatic patients with chronic, severe MR and normal LV ejection fraction values. METHODS AND RESULTS: Regional systolic peak velocities of mitral annular motion during the ejection phase of systole (SW2) were obtained at the mitral annuli of the ventricular septal, lateral, anteroseptal, posterior, anterior and inferior wall sites in the long axis in 31 asymptomatic patients with severe MR (with a regurgitant volume of more than 50 ml) and with EFs more than 60%. The patients were grouped according to their dP/dt values (more or less than 1300 mmHg/s) estimated non-invasively by using continuous Doppler wave of MR SW2 measurements of Group I were higher than Group II in all of the analyzed segments. The difference was statistically significant for all of the segments. SW2 values of the whole study group was moderately correlated with dP/dt measurements in all of the analyzed segments other than the interventricular septum. CONCLUSION: SW2 measurements in the long axis, which are considered to be relatively independent from afterload conditions may be helpful in early detection (while EF is still in normal range) of LV systolic dysfunction during the follow-up of patients with chronic MR.

Time interval from the initiation of the electrocardiographic P wave to the start of left atrial appendage ejection flow: A novel method for predicting atrial fibrillation recurrence.

OBJECTIVE: The incidence of paroxysmal and persistent atrial fibrillation (AF) recurrence is high and unpredictable. In this study, a novel noninvasive method that was thought to reflect the interatrial conduction time was investigated to predict AF recurrence. This method was on the basis of the measurement of time interval from initiation of the electrocardiographic P wave to the start of left atrial (LA) appendage (LAA) ejection flow (P-LAA). METHODS AND RESULTS: Forty-five consecutive patients (age, 61 +/- 11 years; 20 male) with newly diagnosed AF (mean duration, 132 hours; range: 6 hours-3 months) who converted to in sinus rhythm spontaneously or with cardioversion were studied prospectively. Transthoracic and transesophageal echocardiography were performed to measure LA size, mechanical functions, LAA ejection velocity, and P-LAA. Transesophageal echocardiography was performed for the measurement of P-LAA 1 to 2 days after conversion to in sinus rhythm. The patients were followed up for a period of 163 +/- 72 days for the recurrence of AF. AF recurred in 17 (38%) patients after a mean time of 81 +/- 67 days. P-LAA was significantly higher in patients with AF recurrence (123 +/- 36 vs 92 +/- 24 milliseconds, P =.0047) and multiple regression analysis indicated that P-LAA was an independent predictor of AF recurrence. Multiple regression analysis revealed no significant differences in LA size parameters, or in clinical and LA mechanical function parameters recorded after restoration of in sinus rhythm between patients with and without AF recurrence. CONCLUSION: P-LAA may be considered to be an independent predictor of recurrent AF.

Giant eustachian valve with echocardiographic appearance of divided right atrium.

The eustachian valve is an embryologic remnant of the valve of the inferior vena cava. It may be prominent in some individuals, but the echocardiographic appearance of a divided right atrium, as the consequence of a large eustachian valve, is extremely rare. Herein we describe an unusual giant eustachian valve with an echocardiographic appearance of a septal structure dividing the right atrium into 2 separate chambers. This abnormality should be differentiated from cor triatriatum dexter, a very rare cardiac malformation for which it could be mistaken.