Impact of early (3 months) dual antiplatelet treatment interruption prior to renal transplantation in patients with second-generation DES on perioperative stent thrombosis and MACEs.

OBJECTIVE: Early cessation of dual antiplatelet therapy (DAPT) is related to stent thrombosis (ST). The use of second-generation everolimus- and zotarolimus-eluting stents is associated with low restenosis rates and short duration of clopidogrel usage. Non-cardiac surgery in recently stent-implanted patients is associated with major adverse cardiac events (MACEs). Chronic renal failure patients awaiting renal transplantation may also undergo coronary stent implantation prior to surgery. Here we aimed to investigate the safety of early (3 months) DAPT interruption in second-generation drug-eluting stent (DES)-implanted renal transplant recipients. METHODS: In total, 106 previously stent-implanted chronic renal failure patients who underwent renal transplantation were retrospectively enrolled. Three groups were formed according to stent type and the duration of DAPT: early-interruption (3 months from DES implantation), lateinterruption (3-12 months from DES implantation), and bare-metal stent (BMS; at least 1 month from BMS implantation) groups. RESULTS: Comparison among BMS, DES-early and DES-late groups indicated no difference in ST, myocardial infarction, death, and MACEs. In addition, no difference was observed in ST (p=0.998), myocardial infarction (p=0.998), death (p=0.999), and MACEs (p=0.998) between DES-early and DES-late groups. CONCLUSION: Early (3 months) interruption of antiplatelet treatment with second-generation stents before renal transplantation seems to be safe and does not lead to increase in the occurrence of ST and MACEs.

Nocturnal hypoxia and the success rate of standard atrial fibrillation treatment: a case report.

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is one of the extracardiac reasons of atrial fibrillation (AF), and the prevalence of AF is high in SAHS-diagnosed patients. Nocturnal hypoxemia is associated with AF, pulmonary hypertension, and nocturnal death. The rate of AF recurrence is high in untreated SAHS-diagnosed patients after cardioversion (CV). In this study, we present a patient whose SAHS was diagnosed with an apnea test performed in the intensive care unit (ICU) and who did not develop recurrent AF after the administration of standard AF treatment and bi-level positive airway pressure (BiPAP). CASE PRESENTATION: A 57-year-old male hypertensive Caucasian patient who was on medical treatment for 1.5 months for non-organic AF was admitted to the ICU because of high-ventricular response AF (170 per minute), and sinus rhythm was maintained during the CV that was performed two times every second day. The results of the apnea test performed in the ICU on the same night after the second CV were as follows: apnea-hypopnea index (AHI) of 71 per hour, minimum peripheral oxygen saturation (SpO2) of 67%, and desaturation period (SpO2 of less than 90%) of 28 minutes. The patient was discharged with medical treatment and nocturnal BiPAP treatment. The results of the apnea test performed under BiPAP on the sixth month were as follows: AHI of 1 per hour, desaturation period of 1 minute, and minimum SpO2 of 87%. No recurrent AF developed in the patient, and his medical treatment was reduced within 6 months. After gastric bypass surgery on the 12th month, nocturnal hypoxia and AF did not re-occur. Thus, BiPAP and medical treatments were ended. CONCLUSIONS: SAHS can be diagnosed by performing an apnea test in the ICU. SAHS should be investigated in patients developing recurrent AF after CV. Recovery of nocturnal hypoxia may increase the success rate of standard AF treatment.

Tissue Doppler evaluation of the effects of major lung resection on cardiac functions.

OBJECTIVES: The aim of our study was to evaluate the influence of lung resection on cardiac functions by using tissue Doppler echocardiography. STUDY DESIGN: Nineteen consecutive patients (15 males, 4 females; mean age 55+/-8 years) undergoing major lung surgery (16 lobectomy, 3 pneumonectomy) were evaluated in a prospective design. Malignant lung cancer (n=15, 79%) was the major cause for lung surgery. Exclusion criteria were a history of myocardial infarction, angina, atrial fibrillation, valvular heart disease, major arrhythmias, diastolic dysfunction, heart surgery, and FEV1/FVC ratio lower than 60%. Two-dimensional Doppler echocardiography and tissue Doppler imaging (TDI) were performed one or two days before surgery and 4+/-2 weeks postoperatively. RESULTS: Compared to the preoperative measurements, right and left atrial and ventricular dimensions did not differ after surgery (p>0.05). Left ventricular ejection fraction, left ventricular end-systolic and end-diastolic volumes were preserved postoperatively. The following Doppler parameters showed significant changes after surgery: mitral A wave (92+/-23 cm/sec vs. 105+/-27 cm/sec, p=0.005), mitral E/A ratio (1.0+/-0.2 vs. 0.8+/-0.2, p=0.001), tricuspid A wave (65+/-19 cm/sec vs. 80+/-30 cm/sec, p=0.006), and tricuspid E deceleration time (327+/-68 msec vs. 274+/-51 msec, p=0.01). Concerning TDI parameters, there were significant differences in mitral E'/A' ratio (1.0+/-0.4 vs. 0.8+/-0.3, p=0.03) and tricuspid E' wave (9+/-2 cm/sec vs. 8+/-3 cm/sec, p=0.03) after surgery. CONCLUSION: Findings of our study suggest that systolic functions are preserved but diastolic functions are affected after major lung resection in a relatively short time period.

Myocardial perfusion in nonischemic dilated cardiomyopathy with and without atrial fibrillation.

UNLABELLED: Recent studies have shown that idiopathic atrial fibrillation (AF) is associated with diminished myocardial perfusion and perfusion reserve, which are also impaired in various forms of cardiomyopathies. In many cases, AF develops during progression of dilated cardiomyopathy (DCM) and may aggravate heart failure. This study compared myocardial perfusion between patients with nonischemic DCM with and without AF. METHODS: Twelve men (age +/- SD, 55 +/- 12 y) who had DCM and persistent AF were compared with a group of 18 men (mean age, 43 +/- 15 y, P = not statistically significant) who had DCM and sinus rhythm and with 22 healthy controls (mean age, 47 +/- 13 y, P = not statistically significant). Myocardial blood flow (MBF) was noninvasively quantified at rest and during adenosine infusion using PET and radioactive-labeled water (H(2)(15)O PET). RESULTS: Compared with controls, DCM patients without AF showed impaired hyperemic perfusion (2.52 +/- 1.29 vs. 3.57 +/- 0.88 mL/min/mL, P = 0.014) and perfusion reserve (2.10 +/- 1.01 vs. 3.37 +/- 0.97, P = 0.003). However, compared with DCM patients without AF, DCM patients with AF showed an additional impairment in resting perfusion (0.82 +/- 0.31 mL/min/mL, P = 0.010) and hyperemic perfusion (1.32 +/- 0.93 mL/min/mL, P = 0.022), and compared with controls, DCM patients with AF showed a further diminishment of perfusion reserve (1.68 +/- 0.94 vs. 3.37 +/- 0.97, P < 0.001) accompanied by the highest coronary vascular resistance of all groups. CONCLUSION: Compared with patients with sinus rhythm, patients with AF have significantly reduced myocardial perfusion reserve and increased coronary resistance in nonischemic DCM. Further studies on the underlying pathomechanisms are warranted.

Coronary lesion type, location, and characteristics of acute ST elevation myocardial infarction in young adults under 35 years of age.

OBJECTIVE: In the present study, we attempted to analyze the coronary artery lesion characteristics of acute ST elevation myocardial infarction (STEMI) in young patients (aged less than 35 years). METHODS: We retrospectively surveyed 25 038 coronary angiography procedures, which were carried out at The Baskent University Adana Hospital from 1998 to present, to discover acute STEMI in young patients. We studied clinical risk factors and angiographic characteristics in 42 consecutive patients who underwent primary coronary angiography for acute STEMI. Control group (n=42) had no history of coronary artery disease and had angiographically proven normal coronary arteries. All patients were under 35 years of age. Angiographic features for STEMI group were collected and both groups were compared for coronary risk factors. RESULTS: Male sex was more prevalent in acute STEMI group when compared with control participants (83 vs. 59%, respectively; P=0.01). A significant difference was found in cigarette smoking (62 vs. 36%, respectively; P=0.007) and family history (33 vs. 16%, respectively; P=0.03) between the two groups. No statistical significance was observed between the groups in terms of hypertension, diabetes mellitus, total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels. Mean high-density lipoprotein cholesterol level was 33+/-8 mg/dl in STEMI group and 39+/-12 mg/dl in control participants (P=0.02). Young patients with acute STEMI showed a preponderance of single-vessel disease (69%) and acute anterior STEMI (60%) owing to occluded left anterior descending artery (P<0.001). CONCLUSION: We observed risk factors such as family history, smoking, and low high-density lipoprotein cholesterol levels in young adults. Acute anterior STEMI owing to occluded left anterior descending artery was more frequent. Coronary atherosclerosis was characterized by higher presence of type B and proximal lesions. The handling selection was percutaneous coronary intervention in more than half of the patients.

Mean platelet volume is elevated during paroxysmal atrial fibrillation: a marker of increased platelet activation?

Paroxysmal atrial fibrillation might be a risk factor for stroke such as chronic atrial fibrillation. We examined the relation between mean platelet volume and paroxysmal atrial fibrillation to determine the effect of paroxysmal atrial fibrillation on the thrombotic state via elevated mean platelet volume. Mean platelet volume is a marker of platelet size, function, and activation. Increased mean platelet volume reflects active and large platelets that release more thromboxane A2 than smaller ones. We hypothesized that mean platelet volume is elevated in patients with paroxysmal atrial fibrillation. The study population comprised 103 consecutive patients who were detected to have paroxysmal atrial fibrillation by 24-h Holter monitoring and 87 control individuals with normal Holter monitoring. Mean platelet volume and inflammatory parameters were measured. Comprehensive clinical and echocardiographic data were collected. Patients with aortic and mitral stenosis, hyperthyroidism, hypothyroidism, malignancy, infection, and pregnancy were excluded from the study. Mean age of the patients was 63 +/- 11 vs. 45 +/- 14 years (P < 0.001) in paroxysmal atrial fibrillation and control groups, respectively. Fifty-seven patients (55%) in paroxysmal atrial fibrillation and 19 (21%) (P < 0.001) patients in control group were men. Mean platelet volume was significantly higher in the paroxysmal atrial fibrillation group when compared with control group (10.0 +/- 2.0 vs. 8.3 +/- 1.5 fl, respectively; P < 0.001). C-reactive protein (18.5 +/- 28 vs. 3.8 +/- 2 mg/l, respectively; P = 0.004) and erythrocyte sedimentation rate (21 +/- 21 vs. 12 +/- 7 mm/h, respectively; P = 0.01) were also higher in the paroxysmal atrial fibrillation group. There was no difference in white blood cell and platelet counts between groups. In a multivariate analysis, elevated mean platelet volume was associated with the occurrence of paroxysmal atrial fibrillation before and after adjustment for age and sex. Our results indicate that inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate and the marker of platelet size and activity mean platelet volume are elevated in patients with paroxysmal atrial fibrillation.

Heart rate recovery in migraine and tension-type headache.

OBJECTIVE: There are reports proposing that migraine and tension-type headache (TTH) may affect the autonomic nervous system (ANS). Abnormalities in both sympathetic and parasympathetic nervous system have been suggested in migraineurs. However, in TTH, reports on the ANS function are limited and only associated with sympathetic system. Techniques for evaluating parasympathetic activity are more limited when compared with sympathetic function. Hence, the aim of the study was to measure heart rate recovery (HRR), an index of vagal activity, in migraine, TTH, and control subjects. METHODS: Forty-seven episodic migraine, 10 episodic TTH, 11 chronic TTH, and 25 control subjects underwent exercise tolerance test according to modified Bruce protocol, and HRR at 1 minute and 3 minutes (HRR1 and HRR3) were calculated. RESULTS: The HRR 1 and 3 were found to be similar in 3 groups of subjects. However, resting heart rate of migraine and chronic TTH were found to be higher than episodic TTH, but not different from the control group. CONCLUSION: These results suggest that parasympathetic function has not been affected in migraine and TTH patients. However, sympathetic tonus, which is evaluated by resting heart rate, is higher in migraine and chronic TTH than in episodic TTH.

Echocardiographic features of patients with paroxysmal atrial fibrillation.

BACKGROUND: There are several risk factors for the initiation of paroxysmal atrial fibrillation (PAF) and the underlying mechanisms are multifactorial. Our study aims to explore the echocardiographic parameters that can identify in patients with PAF compared to normal subjects. METHODS: Eighty consecutive patients who were with PAF detected by 24-h Holter monitoring (HM) were assigned in our study. The control group (n = 80) consisted individuals with no PAF on HM. Indication for HM was palpitations at rest. All patients underwent routine echocardiographic evaluation. Patients with aortic and mitral stenosis, hyperthyroidism, and hypothyroidism were excluded from the study. Comprehensive clinical data were collected. RESULTS: Mean age of the patients with PAF was 63 +/- 11 years and of those 42% were male subjects. There was no difference in the prevalence of hypertension in both groups. Mean left ventricular ejection fraction (LVEF) was 57 +/- 15% in PAF group and 64 +/- 2% in control subjects (p < 0.001). Mean values of left atrial (LA) diameter for PAF and control groups were 3.7 +/- 0.6 cm vs. 3.1 +/- 0.4 cm (p < 0.001), respectively. Patients with PAF had more severe valve insufficiency, higher values of mean pulmonary artery systolic pressures (PAP) (29 +/- 10 mmHg vs. 25 +/- 2 mmHg, respectively; p = 0.001) and deteriorated MV inflow velocities (E:A ratio 0.9 +/- 0.4 vs. 1.1 +/- 0.3, respectively; p = 0.008) when compared to control group. In multivariate logistic regression analysis, LA diameter predicted the development of PAF after adjusted for age and gender. CONCLUSION: Our results indicate that LA diameter predicts the development of PAF.

Correlation between QTc interval and clinical severity of subarachnoid hemorrhage depends on the QTc formula used.

OBJECTIVES: Subarachnoid hemorrhage (SAH) frequently prolongs QT interval in the acute phase. The purpose of our study is to investigate whether the correlation between electrocardiographic corrected QT interval and the clinical severity of SAH depends on QTc formula used. METHODS: We retrospectively studied 52 consecutive subjects with nontraumatic SAH (extravasation of blood into the spaces covering the central nervous system that are filled with cerebrospinal fluid) who were admitted within the first day of SAH. QT intervals were measured on a standard 12-lead electrocardiography and corrected by Bazett and Hodges formulae. All patients were evaluated according to clinical condition on admission by Hunt-Hess grades. The patients were grouped in two different categories according to QT interval corrected by Bazett and Hodges and scored by Hunt-Hess (HH) grades. RESULTS: Mean age of the study patients was 54 +/- 12 years and of those 31 (60%) were female. Mean values of heart rate and RR interval were 82 +/- 21 bpm and 777 +/- 163 msec, respectively. The mean QTc interval by Bazett and Hodges were 456 +/- 59 msec and 438 +/- 48 msec, respectively (P < 0.001). Twenty-three patients according to Bazett and fifteen according to Hodges had prolonged QTc. Correlation analyses showed relation between HH and QTc and prolonged QTc by Bazett (r = 0.278, P = 0.04 and r = 0.314, P = 0.024; respectively). There was no correlation between HH and QTc and prolonged QTc by Hodges (r = 0.204, P = 0.14 and r = 0.115, P = 0.41; respectively). CONCLUSIONS: In our study, correlation between QTc interval and clinical severity of SAH depended on the QTc formula used.

Value of preoperative echocardiography in the prediction of postoperative atrial fibrillation following isolated coronary artery bypass grafting.

The value of echocardiography, especially tissue Doppler imaging (TDI), in the assessment of risk of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear. One hundred two consecutive patients (80 men; mean age 61 +/- 10 years) who underwent elective isolated CABG were included in the study. All patients underwent conventional transthoracic echocardiography and TDI of the left and right heart before surgery. Also, 24-hour Holter recordings were obtained for all patients. The study end point was the development of postoperative AF. The surgical mortality rate was 2%. Postoperative AF occurred in 18 patients (18%). Patients with postoperative AF have been significantly older than patients without postoperative AF (73 +/- 7 vs 58 +/- 9 years, respectively; p <0.001). Compared with patients without postoperative AF, a significantly higher proportion of patients with postoperative AF experienced paroxysmal AF before surgery (6% vs 33%, respectively; p = 0.001). Patients with postoperative AF had a significantly larger mean left atrial diameter compared with patients without postoperative AF (37 +/- 3 vs 35 +/- 3 mm, respectively; p = 0.012). Multivariate logistic regression analysis identified age as the most significant predictor of postoperative AF (odds ratio 1.254, 95% confidence interval 1.127 to 1.396; p <0.001). Of the echocardiographic variables, only left atrial diameter was identified as a significant predictor of postoperative AF (odds ratio 1.250, 95% confidence interval 1.055 to 1.562; p = 0.047). In conclusion, in the prediction of postoperative AF after isolated CABG, preoperative transthoracic echocardiography, including both conventional echocardiography and TDI, is of little value.

Impaired myocardial perfusion and perfusion reserve associated with increased coronary resistance in persistent idiopathic atrial fibrillation.

AIMS: Patients with atrial fibrillation (AF) present with symptoms of myocardial ischaemia despite exclusion of coronary artery disease. A small vessel disease has been suggested. We quantified myocardial perfusion, perfusion reserve, and coronary vascular resistance (CVR) in AF patients using positron emission tomography (PET). METHODS AND RESULTS: Twenty-five male patients (age: 58 +/- 13 years) with persistent idiopathic AF were compared with 13 age- and risk-matched male controls (age: 56 +/- 8 years). Using H(2)(15)O-PET, myocardial blood flow (MBF) was quantified at rest, at hyperaemia (adenosine), and during cold-pressor-testing (CPT). Scans were repeated 4.1 +/- 2.3 months after cardioversion in 10 AF patients. In AF, resting MBF (0.95 +/- 0.19 vs. 1.14 +/- 0.22 mL/min/mL; P = 0.009), hyperaemic MBF (2.07 +/- 0.80 vs. 3.33 +/- 0.78 mL/min/mL; P < 0.001), and MBF under CPT (0.90 +/- 0.25 vs. 1.14 +/- 0.25 mL/min/mL; P < 0.014) were significantly reduced compared with matched controls. Hyperaemic CVR was increased in AF (47 +/- 21 vs. 29 +/- 7 mmHg x mL/min/mL; P = 0.012) but unchanged at rest and under CPT. After cardioversion, resting MBF and MBF under CPT in AF were similar to matched controls, however, hyperaemic MBF and CVR were not recovered. CONCLUSION: In AF, MBF at baseline, at hyperaemia, and at CPT is reduced, whereas CVR under hyperaemic conditions is increased. Following electrical cardioversion, these findings are partly reversible and therefore most likely secondary to the arrhythmia.

Effects of acute exercise on fibrinolysis and coagulation in patients with coronary artery disease.

Acute physical exertion may trigger an acute coronary syndrome. Furthermore, acute physical exercise may influence hemostatic markers in healthy individuals. However, the effect of acute exercise on blood fibrinolysis and coagulation in patients with coronary artery disease (CAD) is still not well understood. Nineteen untrained patients with angiographically proven CAD (age, 58 +/- 9 years, 12 males), and 25 age- and sex-matched controls without CAD (age, 56 +/- 6 years, 16 males) underwent a treadmill exercise test. Global fibrinolytic capacity (GFC) and prothrombin fragment 1 + 2 (F 1 + 2) levels were measured before exercise, at peak exercise, and 2 hours after recovery. There were no differences between the groups with respect to left ventricular ejection fraction, history of hypertension, body mass index, and serum lipids. Before exercise, GFC was significantly lower in patients with CAD when compared with controls (1.40 +/- 0.43 versus 3.28 +/- 1.19 microg/mL, respectively; P < 0.001). In patients with CAD, F 1 + 2 levels were significantly higher than those of controls (1.15 +/- 0.43 versus 0.79 +/- 0.10 nmol/L, respectively; P = 0.002). In both study groups, GFC levels increased significantly at peak exercise and decreased to baseline values 2 hours after recovery. At peak exercise, F 1 + 2 levels significantly increased in both study groups. However, while F 1 + 2 levels of controls decreased to baseline values 2 hours after recovery (0.79 +/- 0.10 versus 0.80 +/- 0.10 nmol/L; P > 0.05), F 1 + 2 levels of patients with CAD were still significantly elevated (1.15 +/- 0.43 versus 1.84 +/- 0.06 nmol/L; P = 0.002). Acute exercise increases coagulation and fibrinolysis both in untrained subjects with and without CAD. However, in patients with CAD, the equilibrium between fibrinolysis and coagulation during peak exercise is disturbed in favor of coagulation after recovery.

Coronary and systemic stent embolization during percutaneous coronary interventions: a single center experience.

OBJECTIVE: In this study, we attempted to analyze the incidence and outcomes of systemic and coronary stent embolizations during percutaneous coronary interventions and have described the treatment and retrieval methods used. METHODS: We retrospectively studied 24,038 consecutive coronary angiography procedures carried out at The Baskent University Adana Hospital from 1998 to present to determine the total number of stent embolization events. RESULTS: Among them, 4,797 were consecutive coronary stent operations and embolization was encountered in 14 cases (0.29%; 95% CI = 0.14-0.44%, P < 0.0001). The mean age of the patients was 61 +/- 8 years and 78% were men. Stent embolization occurred more frequently in cases with significant proximal angulation. Calcified lesions were not noted in any of the cases. In 7 out of 14 cases, stent embolization occurred at an unknown location and the clinical course was uneventful thereafter. Treatment and retrieval methods of the other 7 cases included the following: 1. Emergency cardiac bypass surgery (3 cases, 43%) 2. Advancement of a low profile delivery balloon through the stent, inflating the balloon, and replacing the stent at the lesion site (3 cases, 43%) 3. Crushing the stent against the coronary wall using another stent (1 case, 14%) 4. 4-loop snare (1 case, failed) None of the cases had bleeding that required transfusion. The stent was not crushed or deployed in the coronary artery causing major cardiac complication in any case. CONCLUSION: Systemic and coronary embolizations of stent procedures are rare. Consequences of coronary stent embolization can lead to prompt cardiac bypass surgery if the retrieval or deployment methods fail. Stent deployment or crushing techniques may be attempted before retrieval in patients who do not suffer from coronary thrombosis and myocardial infarction due to stent embolization.

Autonomic function in tension-type headache.

The pathogenesis of tension-type headache (TTH) is poorly understood. TTH is mostly associated with the sympathetic nervous system. Reports considering autonomic nervous system functioning with regard to TTH are limited. Autonomic nervous system disorders could however play a role in the etiopathology of TTH. Compared with sympathetic nervous system functioning, techniques for evaluating parasympathetic nervous system activity are more limited. Therefore, the aim of the study was to measure heart rate recovery (HRR), an index of vagal activity, in TTH patients. Thirty-seven patients with TTH (15 with episodic and 22 with chronic TTH) and 37 control subjects underwent exercise tolerance testing according to modified Bruce protocol. Heart rate recovery (HRR) at 1 and 3 minutes (HRR1 and HRR3) were calculated. HRR 1 and 3 were found to be similar in patients and controls. However the resting heart rate in patients with episodic TTH was found to be significantly lower than the resting heart rate in patients with chronic TTH and control subjects. These results suggest that parasympathetic nervous system function is not affected in TTH patients. However sympathetic nervous system tonus, which is evaluated by resting heart rate, is low in patients with episodic TTH, suggesting sympathetic hypofunction.

Value of prolonged QRS duration as a predictor of low cardiac output syndrome in patients with impaired left ventricular systolic function who undergo isolated coronary artery bypass grafting.

This study determined whether prolonged QRS duration (QRSd; > or =120 ms) is an independent predictor of low cardiac output syndrome (LCOS) in patients with low left ventricular (LV) ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG). Abnormal LV systolic function places patients at greater risk for developing LCOS after isolated CABG. In patients with this form of ventricular function impairment, prolonged QRSd is associated with adverse hemodynamic effects. Clinical, operative, and outcome data from 190 consecutive patients with LVEF <50% who underwent isolated CABG (mean 62 +/- 9 years of age) were retrospectively analyzed. For all patients, preoperative QRSd was determined. LCOS was the primary outcome investigated. Fifty-seven patients (30%) developed LCOS. Compared with the subgroup without LCOS, the subgroup with this syndrome had significantly larger proportions of patients with LVEF <30% and prolonged QRSd. In addition, the group that developed LCOS had a longer mean QRSd (117 +/- 25 vs 102 +/- 17 ms, respectively, p = 0.00003) and a significantly higher frequency of adverse postoperative outcomes. Hospital stay was significantly longer in the subgroup with LCOS than in the subgroup without. Multivariate logistic regression analysis identified prolonged QRSd as the most significant predictor of LCOS. LVEF <30%, diuretic therapy, and preoperative risk score (European System for Cardiac Operative Risk Evaluation) were also identified as independent predictors of LCOS. In conclusion, in patients with impaired LV systolic function, prolonged QRSd is a highly significant predictor of LCOS development after isolated CABG.

Impact of sympathetic innervation on recurrent life-threatening arrhythmias in the follow-up of patients with idiopathic ventricular fibrillation.

PURPOSE: Idiopathic ventricular fibrillation (IVF) is defined as VF in the absence of any identifiable structural or functional cardiac disease. The underlying pathophysiological mechanisms are unknown. This study was performed to investigate the potential impact of sympathetic dysfunction, assessed by (123)I-meta-iodo-benzylguanidine scintigraphy ((123)I-MIBG SPECT), on the long-term prognosis of patients with IVF. METHODS: (123)I-MIBG SPECT was performed in 20 patients (mean age 37+/-13 years) with IVF. Mean follow-up of patients after study entry was 7.2+/-1.5 years (range 4.9-10.5 years). Ten patients (five men, five women; mean age 43+/-12 years; p=NS versus study group) with medullary carcinoma of the thyroid gland served as an age-matched control group. RESULTS: Abnormal (123)I-MIBG uptake was observed in 13 patients (65%). During follow-up, 18 episodes of VF/fast polymorphic ventricular tachycardias occurred in four IVF patients with abnormal (123)I-MIBG uptake whereas only two episodes of monomorphic ventricular tachycardia (and no VF) occurred in a single IVF patient with normal (123)I-MIBG uptake. CONCLUSION: Impairment of sympathetic innervation may indicate a higher risk of future recurrent episodes of life-threatening ventricular tachyarrhythmias in patients with IVF. Studies in larger cohorts are required to validate the significance of (123)I-MIBG SPECT during the long-term follow-up of these patients.

Prognostic value of tissue Doppler imaging in patients with chronic congestive heart failure.

BACKGROUND: The prognostic value of tissue Doppler imaging (TDI) in patients with chronic congestive heart failure (CHF) has not been compared against conventional measures of systolic, diastolic and overall left ventricular LV performance. The aim of this study was to assess the prognostic value of TDI-derived parameters in patients with CHF. METHODS: One hundred thirty-two subjects with chronic CHF [due to ischemic (n=82) or dilated (n=50) cardiomyopathy, 101 males, mean age 57+/-11 years] underwent conventional two-dimensional/Doppler echocardiography and assessment of the Tei-index (isovolumic contraction time and isovolumic relaxation time divided by ejection time). Systolic, early and late diastolic mitral annular velocities (S', E' and A') were derived from pulsed TDI. A cardiac event (cardiac death, urgent cardiac transplantation or hospitalization due to decompensated CHF) was defined as the combined study endpoint. RESULTS: The patients were followed for a mean of 224+/-123 days. Thirty-one patients suffered an event (cardiac death, n=5; urgent cardiac transplantation, n=2; hospitalization due to CHF, n=24). In patients with event, ejection fraction was lower (25+/-10 vs. 32+/-9%), mitral deceleration time was shorter (138+/-58 vs. 193+/-72 ms), and the peak mitral E/E'-ratio (16.1+/-6.6 vs. 10.6+/-5.0) was significantly elevated as compared to patients free of events (p<0.001 for all comparisons). In those patients, the Tei-index was elevated (1.09+/-0.39 vs. 0.86+/-0.26, p<0.01), and a restrictive mitral filling pattern was more frequent (51.6 vs. 17.5%, p<0.001). Stepwise multivariate analysis identified the mitral E/E'-ratio (p<0.001) and the Tei-index (p=0.019) as the only independent predictors of a combined event. E/E'-ratio was the best predictor of hospitalization due to CHF also. In patients with mitral E/E'-ratio>12.5 or Tei-index>0.90, outcome was poor. CONCLUSIONS: In subjects with chronic CHF, the mitral E/E'-ratio is a stronger predictor of future cardiac events than conventional parameters of systolic, diastolic or overall LV performance. The E/E'-ratio may be a useful addition in the routine follow-up of such patients.

Implantable cardioverter/defibrillator therapy in arrhythmogenic right ventricular cardiomyopathy: single-center experience of long-term follow-up and complications in 60 patients.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a major cause of ventricular tachycardia (VT) and cardiac arrest in young patients. We hypothesized that treatment with implantable cardioverter/defibrillators (ICDs) is safe and improves the long-term prognosis of ARVC patients at high risk of sudden death. METHODS AND RESULTS: Sixty patients with ARVC (aged 43+/-16 years) were treated with transvenous ICD systems. Despite a higher number of right ventricular sites tested for adequate lead positions (P<0.05), lower R-wave amplitudes (P<0.001) were achieved in ARVC patients compared with other entities. During follow-up of 80+/-43 months (396 patient-years), event-free survival was 49%, 30%, 26%, and 26% for appropriate ICD therapies and 79%, 64%, 59%, and 56% for potentially fatal VT (>240 bpm) after 1, 3, 5, and 7 years, respectively. Multivariate analysis identified extensive right ventricular dysfunction as an independent predictor of appropriate ICD discharge. Fifty-three adverse events occurred in 37 patients during the perioperative (n=10) or follow-up (n=43) period, mainly related to the leads (n=31 in 21 patients). No lead perforation was observed. Freedom from adverse events was 90%, 78%, 56%, and 42% and freedom from lead-related complications was 95%, 85%, 74%, and 63% after 1, 3, 5, and 7 years, respectively. CONCLUSIONS: These results strongly suggest an improvement in long-term prognosis by ICD therapy in high-risk patients with ARVC. However, meticulous placement and long-term observation of transvenous lead performance with focus on sensing function are required for the prevention and/or early recognition of disease progression and lead-related morbidity during long-term follow-up of ICD therapy in ARVC.