Successful Aorta-osteal Stenting after Iatrogenic Acute Type-A Aortic Dissection during Primary Percutaneous Coronary Intervention.

BACKGROUND: Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. This complication, if not managed urgently, can have critical results. CASE REPORT: We present the case of a 70 year-old woman who was treated by primary percutaneous coronary intervention (PCI) of the right coronary artery (RCA) for acute inferior myocardial infarction; however, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to heal the RCA and restrict the retrograde propagation to the ascending aorta. The aortic dissection was monitored by means of computerised tomography and the dissection repaired itself spontaneously within a day. CONCLUSION: Treatment of the aorta coronary dissection (ACD) by urgent osteal stenting is a less invasive treatment compared with surgical treatment in appropriate cases. We demonstrated that immediate osteal stenting should be performed in ACD.

QT dispersion on ECG in acute ischemic stroke and its impact on early prognosis.

OBJECTIVE: To evaluate the effects of corrected QT dispersion (QTcd) on patients` prognosis with early stage non-lacunar ischemic stroke, regardless of location of the lesion. METHODS: In this non-randomized prospective study, stroke patients were evaluated in the intensive care unit of Cukurova University Hospital, School of Medicine, Adana, Turkey, from 2002-2003. Neurologic symptoms of all subjects were recorded according to Glasgow Coma Scale (GCS) and Canadian Neurological Scale. Subtypes of stroke were defined according to the Oxfordshire Community Stroke Project classification. Patients with GCS between 7 and 11 were included in the study. Electrocardiograms of the patients were collected in the first 6 hours. Corrected QT (QTc) were calculated by the Bazzett formula. Corrected QT dispersion was defined as maximum minus minimum QT interval. RESULTS: A total of 148 (74 male) consecutive acute stroke patients, aged between 36-90 years (mean 63.07 +/- 12.55), were divided into 2 groups. Group I consisted of surviving patients (n=109) and Group II consisted of expired patients (n=39). There were no statistically significant differences in the mean age, gender distribution, frequency of hypertension, diabetes mellitus, and coronary artery disease between the groups. Group II (7.4 +/- 3.7) had significantly higher QTcd (7.4 +/- 3.7) compared to Group I (p=0.002). CONCLUSION: This study shows the value of QTcd in predicting patients` prognoses with early stage non-lacunar ischemic stroke, regardless of location of the lesion.

Global aphasia due to left thalamic hemorrhage.

Global aphasia is an acquired language disorder characterized by severe impairments in all modalities of language. The specific sites of injury commonly include Wernike's and Broca's areas and result from large strokes--particularly those involving the internal carotid or middle cerebral arteries. Rarely, deep subcortical lesions may cause global aphasia. We present three cases with global aphasia due to a more rare cause: left thalamic hemorrhage. Their common feature was the large size of the hemorrhage and its extension to the third ventricule. HMPAO-SPECT in one of the cases revealed ipsilateral subcortical, frontotemporal cortical and right frontal cortical hypoperfusion. Left thalamic hemorrhage should be considered in the differential diagnosis of global aphasia.

Left ventricular diastolic function and circadian variation of blood pressure in essential hypertension.

The purpose of this prospective study was to determine the relationship between circadian blood pressure and left ventricular diastolic function in essential hypertension. The study population included 25 patients aged 56 +/- 18 years with non-dipper hypertension and 25 age- and sex-matched patients with dipper hypertension. They underwent conventional Doppler echocardiography and color tissue Doppler from apical 4- and 2-chamber views. In non-dipper patients, diastolic left ventricular function was reduced significantly. The transmitral E wave decreased (0.55 +/- 0.2 vs 0.62 +/- 0.2 m/s, P < 0.05), the transmitral A wave increased (0.77 +/- 0.1 vs 0.70 +/- 0.1 m/s, P < 0.01), the transmitral E/A ratio decreased (0.78 +/- 0.1 vs 0.86 +/- 0.2, P < 0.05), and the transmitral E-wave deceleration time increased in non-dipper patients (211 +/- 44 vs 196 +/- 42 ms, P < 0.05). The isovolumic relaxation time increased (112 +/- 15 vs 105 +/- 14 m/s, P < 0.05). The mean left ventricular myocardial velocities also differed significantly; the early diastolic velocity decreased (5.9 +/- 2. 1 vs 77 +/- 3.1 cm/s, P < 0.01), the late diastolic velocity increased (9.5 +/- 2.7 vs 8.7 +/- 1.6 cm/s, P < 0.05), and the E/A ratio decreased (0.68 +/- 0.55 vs 0.94 +/- 0.39, P < 0.01). These findings suggest that non-dipper hypertensive patients who have impaired left ventricular diastolic function should be identified early for careful follow-up and possible referral to a specialized center.

Anomalous left coronary artery arising from the right sinus of Valsalva: a case report.

We report a case of 56-year-old man whose coronary angiography showed a single coronary artery arising from a single ostium in the right sinus of Valsalva.

Unique spontaneous unhealed chronic multivessel coronary artery dissection in an elderly man: a case report and review of the literature.

Spontaneous coronary artery dissection (SCAD) is relatively uncommon. It often occurs in healthy, middle-aged women without overt risk factors for atherosclerosis and is associated with the peripartum period. The pattern and severity of presentation are variable. There are only 5 reports in the literature about multivessel involvement. The etiopathogenesis of SCAD is unclear. Treatment strategy is not standard but is usually tailored to clinical features. Long-term survival of patients with SCAD who have had no problem at the initial event is good. The authors report the first case of unhealed chronic multivessel SCAD in the literature.

Myocardial Ischemia caused by a coronary anomaly: left circumflex coronary artery arising from right sinus of valsalva.

We present the case of a patient in whom a previously undetected anomalous origin of the circumflex coronary artery caused myocardial ischemia and led to positive myocardial scintigraphic results. Subsequent coronary angiography showed that the left circumflex coronary artery arose from the right coronary ostium-an anomaly that has been associated with chest discomfort-without atherosclerotic lesions. The peripheral distribution of the left circumflex artery was normal. We describe the clinical and angiographic findings in our patient and discuss the relationship between coronary artery anomalies and ischemia.

Transient parkinsonism: induced by progesterone or pregnancy?

We report on the development of transient parkinsonism after progesterone injection in a pregnant patient with a risk of abortion. Etiological possibilities are discussed, including pregnancy itself, possible toxic effects of the dead fetus, and progesterone injection. Progesterone-induced parkinsonism seems the most likely diagnosis in this case.

Left ventricular hydatid cyst presenting with acute ischemic stroke: case report.

Cardiac hydatid cysts are rarely seen. The presentation of an acute stroke secondary to embolization from a cardiac hydatid cyst is also rare. We report a young boy with left ventricular hydatid cyst who presented with acute ischemic stroke.

Assessment of cardiac autonomic regulation in children with monosymptomatic nocturnal enuresis by analysis of heart rate variability.

The pathogenesis of monosymptomatic nocturnal enuresis is controversial. Various urodynamic studies showed bladder hyperactivity in enuretic children. But the exact cause is not precisely known. The aim of this study was to understand whether the autonomic nervous system dysfunction is involved in this bladder hyperactivity or not. Heart rate variability measurement is widely used for evaluation of cardiac autonomic activity. We evaluated cardiac autonomic nervous system functions in monosymptomatic nocturnal enuretic children by using 24-hour Holter electrocardiogram. The study group consisted of 32 enuretic children (20 boys and 12 girls) and the control group consisted of 20 healthy children (12 boys and 8 girls). In these two groups, we assessed cardiac autonomic regulation by analysis of heart rate variability, and found a significantly higher parasympathetic activity in enuretic children than controls. We suggest that the parasympathetic nervous system hyperactivity plays a role in nocturnal enuresis by causing vesical hyperactivity in monosymptomatic enuretic children.

Effects of dipper and non-dipper status of essential hypertension on left atrial mechanical functions.

AIM: This study was designed in order to investigate the effects of dipper and non-dipper status of hypertension on left atrial mechanical (reservoir, conduit and booster pump) functions with left atrial volume measurements by means of two-dimensional echocardiography in untreated systemic hypertensive patients. METHOD: A total of 27 untreated dipper hypertensive patients, group I (15 female, 12 male, mean age 57+/-12 years); 23 untreated non-dipper hypertensive patients, group II (12 female, 11 male, mean age: 53+/-18 years); and 25 voluntary healthy individuals, group III (13 female, 12 male, mean age 53+/-10 years) were included into the study. Twenty-four hour blood pressure (BP) measurement was performed by the cuff-oscillometric method to evaluate the nocturnal decrease of BP. The patients whose night time mean blood pressure measurements were found 10% or more lower compared to mean day time measurements were classified as dipper hypertensive patients and the ones with a decrease of less than 10% were classified as non-dipper hypertensive patients. Left atrial (LA) volumes were measured echocardiographically according to biplane area-length method in apical four-chamber and two-chamber views. LA maximal volume (V(max)) was recorded at the onset of mitral opening, LA minimal volume (V(min)) was recorded at the onset of mitral closure and LA presystolic volume (V(p)) was recorded at the beginning of the atrial systole (p wave on ECG). All volume measurements were corrected to body surface area, and following LA emptying functions parameters were calculated: LA passive emptying volume (LAPEV)=V(max)-V(p), LA passive emptying fraction (LAPEF)=LAPEV/V(max), Conduit volume (CV)=left ventricular output volume-(V(max)-V(min)), LA active emptying volume (LAAEV)=V(p)-V(min), LA active emptying fraction (LAAEF)=LAAEV/V(p), LA total emptying volume (LATEV)=V(max)-V(min), LA total emptying fraction (LATEF)=LATEV/V(max). RESULTS: LA volume indexes, V(max), V(min), and V(p), were significantly increased in the hypertensive subgroups (groups I and II) than in controls (p<0.001, p<0.001, p<0.001, respectively), but no significant difference was found in the V(p) values between group I and group II. V(max) and V(min) were larger in non-dipper hypertensive group than in dipper hypertensive group (p<0.05 and p<0.05, respectively). LAPEV and LAPEF were observed to be significantly reduced in both dipper and non-dipper hypertensives than in control (p<0.001 and p<0.05, respectively), and this difference was more obvious in non-dipper than dipper cases (p<0.001). Conduit volume was significantly lower in hypertensive groups than controls (p<0.05). LA active emptying volume (p<0.001) and LAA active emptying fraction (p<0.001) were significantly greater in hypertensive cases than in controls. Furthermore, LA active emptying volume in non-dipper hypertensive subjects was significantly greater than dipper hypertensive cases (p<0.05). Left atrial total emptying volume and left atrial total emptying fraction in both hypertensive groups were similar to control (p>0.05). CONCLUSIONS: Atrial reservoir and booster pump functions increase in hypertensive patients, but this result is more prominent in non-dipper hypertensives than in dipper hypertensive patients.

Cardiac autonomic activity in obstructive sleep apnea: time-dependent and spectral analysis of heart rate variability using 24-hour Holter electrocardiograms.

To analyze the function of cardiac autonomic regulation in patients with obstructive sleep apnea syndrome (OSAS), we enrolled 36 patients with OSAS and divided them according to the apnea hypopnea index (AHI) into 2 groups: Group I (n=19) had mild OSAS (AHI < 20) and Group II (n=17) had severe OSAS (AHI > or = 20). The findings were compared with those of 24 healthy control subjects who were matched for age, sex, blood pressure, and body mass index. All participants underwent 24-hour Holter monitoring, with continuous time-dependent and spectral analysis of heart rate variability. In addition, we performed arrhythmia analysis. Frequent or repetitive ventricular arrhythmias (> or = 30 premature ventricular beats/hour) were detected in 15 (42%) patients with OSAS and in 6 (25%) members of the control group. In both mild and severe OSAS, SDNN was significantly lower than in controls, and SDANN findings were similar. In mild OSAS, RMSSD values were not significantly lower than in controls, but in severe OSAS they were. The ULF, VLF, LF and LF/HF values of both groups of OSAS patients were significantly higher than those of controls, but their HF values were lower. The mean LF/HF ratio during the same period was significantly higher in Group II than in Group I and the control group. Our results suggest that cardiac autonomic activity may be altered in patients with OSAS throughout a 24-hour period, that this alteration occurs even in the absence of hypertension, heart failure, or other disease states, and that it is linked to the severity of OSAS.

Treatment of intracoronary thrombus using tirofiban in a patient with normal coronary arteries.

We report a 64-year-old Turkish man who presented with unstable angina pectoris. Coronary angiography revealed massive intracoronary thrombus, which completely occluded the distal part of the left circumflex coronary artery. The thrombotic segment and the rest of the coronary tree were free of atherosclerosis. The patient was treated with intravenous tirofiban, a glycoprotein IIb/IIIa inhibitor. A control angiography was performed one week later and showed total dissolution of the thrombus with tirofiban therapy.

Pulmonary endarteritis and subsequent embolization to the lung as a complication of a patent ductus arteriosus--a case report.

The authors describe a case of pulmonary endarteritis and subsequent embolization to the lungs as a complication of a patent ductus arteriosus (PDA). Although 2-dimensional echocardiography has been shown to be of great value in the diagnosis of patients with infective endocarditis, echocardiographic detection of vegetation within the pulmonary artery and subsequent embolization to the lung is extremely rare and, to our knowledge, has been previously reported only in a few cases. In brief, our case not only shows the importance of echocardiography in making this rare diagnosis but also emphasizes the role of echocardiography as an effective means of following up such a case.

Left atrial appendage aneurysm presenting with recurrent embolic strokes.

A case of left atrial appendage aneurysm is described in a 40-year-old man, who presented with recurrent embolic strokes and was asymptomatic until the last 6 months. Chest X-ray revealed a slightly prominent upper left heart border. The diagnosis was made by transthoracic two-dimensional echocardiography and confirmed by transesophageal echocardiography, magnetic resonance imaging and also by surgery.

Levels of serum IL-1beta, IL-2, IL-8 and tumor necrosis factor-alpha in patients with unstable angina pectoris.

OBJECTIVES: Inflammation is the most important mechanism of plaque disruption playing an essential role in acute coronary syndromes. It is controversial whether the inflammatory mediators are the cause or the result in the development of plaque rupture. Stimulation of interleukins increases adhesion molecules, fibrinogen and plasminogen activator inhibitors,which cause the activation of inflammation and thrombosis. However, the importance of interleukins in acute coronary syndromes has not been clearly defined. We did not find any article concerning relations between the levels of serum interleukin(IL)-1beta, IL-2, IL -8 and tumor necrosis factor (TNF)-alpha in patients with unstable angina pectoris (UAP). So the aim of this study was to determine the levels of serum I -1b, IL-2, IL-8 and TNF-alpha during the early stage of UAP. METHODS AND RESULTS: Thirty-seven patients with UAP(12 females and 25 males; mean age, 57.5 +/- 9.7 years) within 6 h of admission and 20 healthy volunteers(eight females and 12 males; mean age, 51.3 +/- 6.3 years) were included in the study. IL-1beta, IL-2, IL-8 and TNF-alpha levels were measured using the enzyme-linked immunosorbent assay method. Patients with acute or chronic inflammation, renal failure or chronic heart failure were excluded from the study. The age, gender and risk factors of the study and control groups were similar. The levels of IL-1beta, IL-8 and TNF-alpha were significantly increased (p < /0.0001, p < /0.001 and p < /0.016, respectively) in patients with UAP. There was no difference of IL-2 levels between the UAP group and controls. CONCLUSION: We detected high levels of IL-1beta, IL-8 and TNF-alpha in patients with UAP during early phase. We suggest that proinflammatory cytokines (e.g. IL-1beta,IL-8, TNF-alpha) may play an important role in the development of atherosclerosis and its complications.