The Initial Part of Polymorphic Ventricular Tachycardia as a Clue for the Sustainability of Tachycardia and Ablation Success: A Varying Degree of Purkinje-Myocardial Complicity?

The cardiac Purkinje system is capable of very rapid burst activity suggestive of its potential role in being a driver of polymorphic ventricular tachycardia (VT) (PMVT) or ventricular fibrillation (VF). It plays a pivotal role, however, not only in the triggering of but also the perpetuation of ventricular arrhythmias. A varying degree of Purkinje-myocardial complicity has been blamed in determining not only the sustained or non-sustained nature of PMVT but also the pleomorphism of the non-sustained runs. The initial part of PMVT before cascading to the whole ventricle to establish disorganized VF can give important clues for ablation of PMVT and VF. We present a case of an electrical storm after acute myocardial infarction that was successfully ablated after identifying Purkinje potentials that triggered polymorphic, monomorphic, and pleiomorphic VTs and VF.

Adjunctive lacosamide treatment for adult focal-onset epilepsy: focus on comorbid intellectual/developmental disorders and differing responses.

BACKGROUND: Data regarding lacosamide treatment as an adjunctive therapy in patients representative of a focal-onset epilepsy population including those with and without intellectual/developmental disorders (IDDs) are limited. PURPOSE: To evaluate the retention rates of lacosamide in focal-onset epilepsy patients with and without IDD. PATIENTS AND METHODS: We retrospectively reviewed all consecutive electronic and paper medical records of patients diagnosed with focal-onset epilepsy who were treated with lacosamide in two tertiary epilepsy centers. RESULTS: One hundred and thirty-six patients who met the inclusion criteria were studied. Number of patients with IDD was 46 (33.8%). Median lacosamide dose was 300 mg/day. A total of 39 patients (28.7%) experienced side effects, and 22 of them (16.2%) discontinued lacosamide. The 1-, 2-, and 3-year retention rates of lacosamide in patients with IDD were 68%, 62%, and 53%, respectively. Kaplan-Meier survival analysis showed that the retention rates were significantly lower in patients with IDD when compared to patients without IDD (P=0.04). Cox regression analysis showed that concomitant use of sodium channel blocker antiepileptic drugs (AEDs) was the only independent predictor of retention rate of lacosamide treatment (P=0.03). In the subgroup of patients with IDD, the analysis was performed again and the number of background AEDs was the only predictor for the retention rate of lacosamide (P=0.04). CONCLUSION: When compared to patients without IDD, retention rates of lacosamide adjunctive therapy were lower in patients with IDD. However, these rates were higher than the rates suggested with previously registered AEDs including lamotrigine, levetiracetam, and topiramate. Therefore, irrespective of having comorbid IDD, we might suggest that lacosamide is a well-retained drug with a high efficacy profile in patients with focal-onset epilepsy.

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

RATIONALE: Pulmonary embolism (PE) is a common diagnostic consideration for patients who present to the emergency department (ED) with chest pain, dyspnea, or both. In addition, PE has a very high mortality in patients who are hemodynamically unstable. An electrocardiography, bedside transthoracic echocardiogram, and computed tomography pulmonary angiogram are usually performed to confirm the diagnosis. PATIENT CONCERNS: A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking. DIAGNOSIS: During synchronous recording of echocardiographic images, a large mobile thrombus detached from the right atrium, and first embolized to the right ventricle and then to the main pulmonary artery from the right heart chambers. Soon after, shortness of breath developed which clinically worsened the patient. Transthoracic echocardiogram which demonstrated the thrombus in the pulmonary artery or right heart chambers was suspected of causing acute massive PE. INTERVENTIONS: The patient was transferred to Critical Care Unit for monitoring; 100 mg of alteplase was initiated immediately and alleviated the hemodynamic instability within 2 hours of intravenous administration. OUTCOMES: To the best of our knowledge, this is the first synchronous echocardiographic recording showing the embolization of a thrombus from the right atrium, first to the right ventricle and then to the main pulmonary artery. LESSONS: Transthoracic echocardiography provides a safe, rapid, and noninvasive diagnostic tool for evaluation of suspected massive PE. Thrombolytic therapy is useful for treating acute massive PE that leads to hemodynamic instability.

Consideration of difficulties and exit strategies in a case of face allotransplantation resulting in failure.

We describe the first rescue procedure in a case of total face allotransplantation. The recipient was a 54-year-old man with severe disfigurement of the entire face following an accidental gunshot injury 5 years previously. The large defect included the maxilla, mandible, and mid-face. Full face procurement was performed from a multiorgan cadaveric donor and was allotransplanted to the recipient. The post-transplant induction immunosuppressive regimen included ATG combined with tacrolimus, mycophenolate mofetil, and prednisone, while maintenance was provided by the last three of these. Although the early postoperative period was uneventful, squamous cell carcinoma developed in the upper and lower extremities in the fifth postoperative month, and post-transplant lymphoproliferative disorder (PTLD) occurred in the sixth month postoperatively. Malignancies were treated, involving both surgical and medical approaches. The patient developed opportunistic pulmonary and cerebellar aspergillosis. In order to reduce the adverse affects and metabolic and immunological load, the transplanted face was removed and replaced with a free flap. Although the early postoperative period was promising, with the transferred flap surviving totally and all vital signs and general status appearing to be improving, the patient was eventually lost due to complicated infectious and metabolic events. Although this case was unsuccessful, we suggest that the immunological and metabolic load should be reduced as soon as stable medical conditions are established in case of diagnosis of a situation involving a high rate of mortality, such as PTLD and untreatable opportunistic infections. This should include withdrawal of all immunosuppressive drugs and removal of all allotransplanted tissues.

Arrhythmogenic Noncompaction Cardiomyopathy: Is There an Echocardiographic Phenotypic Overlap of Two Distinct Cardiomyopathies?

The clinical diagnosis of right ventricular (RV) cardiomyopathies is often challenging. It is difficult to differentiate the isolated left ventricular (LV) noncompaction cardiomyopathy (NC) from biventricular NC or from coexisting arrhythmogenic ventricular cardiomyopathy (AC). There are currently few established morphologic criteria for the diagnosis other than RV dilation and presence of excessive regional trabeculation. The gross and microscopic changes suggest pathological similarities between, or coexistence of, RV-NC and AC. Therefore, the term arrhythmogenic right ventricular cardiomyopathy is somewhat misleading as isolated LV or biventricular involvement may be present and thus a broader term such as AC should be preferred. We describe an unusual case of AC associated with a NC in a 27-year-old man who had a history of permanent pacemaker 7 years ago due to second-degree atrioventricular block.

Why aortic elasticity differs among classical and non-classical mitral valve prolapsed?

BACKGROUND: Mitral valve prolapse (MVP) is the most common valvular heart disease and characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are two types of MVP, broadly classified as classic (thickness ≥5 mm) and non-classic (thickness <5 mm) according to the morphology of the leaflets. We aimed to investigate elastic properties of the aorta in young male patients with classical and non-classical MVP. MATERIAL/METHODS: In the present study, 63 young adult males (mean age: 22.7 ± 4.2) were included. Patients were divided into classic MVP (n = 27) and non-classic MVP (n = 36) groups. Aortic strain, aortic distensibility and aortic stiffness index were calculated by using aortic diameters obtained by echocardiography and blood pressures measured by sphygmomanometer. RESULTS: There was no significant difference between the groups in terms of age, body mass index, left ventricular mass and ejection fraction. When comparing the MVP group it was found that aortic strain and aortic distensibility were increased (p = 0.0027, p = 0.016, respectively) whereas the aortic stiffness index was decreased (p = 0.06) in the classical MVP group. CONCLUSION: We concluded that the elastic properties of the aorta is increased in patients with classic MVP. Further large scale studies should be performed to understand of morphological and physiological properties of the aorta in patients with MVP.

Normal coronary myocardial infarct is innocent or guilty? A case of ventricular septal rupture secondary to normal coronary myocardial infarction.

Prognosis of cases of myocardial infarction with normal coronary arteries (MINCA) is known to be better than acute myocardial infarction cases with obstructive coronary lesions. A MINCA case causing ventricular septal rupture is rare. Herein, we present a 70-year-old female MINCA case which caused ventricular septal rupture which is a fatal complication of acute myocardial infarction. .

Blunted heart rate recovery is associated with exaggerated blood pressure response during exercise testing.

Increased sympathetic activity and endothelial dysfunction are the proposed mechanisms underlying exaggerated blood pressure response to exercise (EBPR). However, data regarding heart rate behavior in patients with EBPR are lacking. We hypothesized that heart rate recovery (HRR) could be impaired in patients with EBPR. A total of 75 normotensive subjects who were referred for exercise treadmill test examination and experienced EBPR were included to this cross-sectional case-control study. The control group consisted of 75 age- and gender-matched normotensive subjects without EBPR. EBPR was defined as a peak exercise systolic blood pressure (BP) ≥210 mmHg in men and ≥190 mmHg in women. HRR was defined as the difference in HR from peak exercise to 1 min in recovery; abnormal HRR was defined as ≤12 beats/min. These parameters were compared with respect to occurrence of EBPR. Mean values of systolic and diastolic BP at baseline, peak exercise, and the first minute of the recovery were significantly higher in the subjects with EBPR. Mean HRR values were significantly lower (P < 0.001) in subjects with EBPR when compared with those without. Pearson's correlation analysis revealed a significant positive correlation between the decrease in systolic BP during the recovery and degree of HRR in individuals without EBPR (r = 0.42, P < 0.001). Such a correlation was not observed in subjects with EBPR (r = 0.11, P = 0.34). The percentage of abnormal HRR indicating impaired parasympathetic reactivation was higher in subjects with EBPR (29 % vs 13 %, P = 0.02). In logistic regression analyses, HRR and resting systolic BP were the only determinants associated with the occurrence of EBPR (P = 0.001 and P < 0.001, respectively). Decreased HRR was observed in normotensive individuals with EBPR. In subjects with normal BP response to exercise, a linear correlation existed between the degree of HRR and decrease in systolic BP during the recovery period. However, such a correlation was not found in subjects with EBPR. Our data suggest that mechanisms underlying the blunting of the HRR might be associated with the genesis of EBPR. The association between the extent of HRR and adverse cardiovascular outcomes in patients with EBPR needs to be investigated in detail in future research.

P-wave parameters and cardiac repolarization indices: does menopausal status matter?

BACKGROUND AND PURPOSE: Data regarding electrocardiographic characteristics of postmenopausal women are lacking. In this prospective, cross-sectional study, electrocardiographic P-wave parameters and cardiac repolarization indices of age-matched pre- and postmenopausal healthy women were compared. We hypothesized that menopausal status would have a significant effect on cardiac electrical activity and hence electrocardiography (ECG) recordings. MATERIALS AND METHODS: Twelve-lead ECG recordings were obtained from 125 consecutively recruited postmenopausal healthy women aged between 44 and 54 years. The control group consisted of 125 age-matched premenopausal women. P-wave parameters and cardiac repolarization indices were measured and compared with respect to menopausal status. RESULTS: Demographic features of premenopausal and postmenopausal women were comparable. There were no significant differences between two groups regarding mean values of heart rate, maximum and minimum P-wave duration, P-wave dispersion, maximum and minimum QT interval, and QT dispersion. Mean values of QT interval obtained from lead V5 were also similar. Corrected values which were calculated according to Bazett and Fridericia formulas also did not differ between the groups. Mean values of Tpeak to Tend (TpTe) (p<0.001) and corrected TpTe (p=0.001) intervals obtained from lead V5 were significantly shorter in postmenopausal women when compared to those without menopause. CONCLUSION: Tpeak to Tend interval decreased significantly while QT intervals and P-wave parameters did not change in postmenopausal women when compared to premenopausal women. Association of these findings with changes in levels of sex steroids and their prognostic implications need to be elucidated with further studies.

P-wave dispersion for predicting paroxysmal atrial fibrillation in acute ischemic stroke.

BACKGROUND: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P(d)) might be a useful marker in predicting PAF in patients with acute ischemic stroke. METHODS: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared. RESULTS: Maximum P-wave duration (p=0.002), P(d) (p<0.001) and left atrium diameter (p=0.04) were significantly higher in patients with PAF when compared to patients without PAF. However, in binary logistic regression analysis P(d) was the only independent predictor of PAF. The cut-off value of P(d) for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (p<0.001). On a single 12-lead ECG, a value higher than 57.5 msc predicted the presence of PAF with a sensitivity of 80% and a specificity of 73%. CONCLUSION: P(d) on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

[Evaluation of clinical and demographic characteristics and their association with length of hospital stay in patients admitted to cardiac intensive care unit with the diagnosis of acute heart failure]. / Akut kalp yetersizligi nedeni ile kardiyoloji yogun bakim ünitesine yatirilan hastalarin klinik ve demografik özelliklerinin ve bu özelliklerin hastanede kalis süresi ile iliskisinin incelenmesi.

OBJECTIVE: Despite increasing incidence, data regarding clinical and demographic characteristics of patients with acute heart failure (AHF) admitted to cardiac intensive care unit (ICU) are inconclusive. The aim of this study was to assess the presentation characteristics and factors determining the length of hospital stay in this particular patient population. METHODS: We conducted a single-center, prospective study involving 150 patients hospitalized to cardiac ICU with the primary diagnosis of AHF. Chi-square and Student t tests were used for the analysis of categorical and continuous variables, respectively. Linear regression analysis (LRA) was used to determine the factors affecting the length of hospital stay. RESULTS: Forty-nine percent of the patients had new-onset AHF and 25% had preserved left ventricular ejection fraction (LVEF). In 25.3% of all patients and 46.6% of the patients with new-onset HF the precipitating factor was acute coronary syndrome. Atrial fibrillation and valvular heart disease as precipitating factors were more common in patients with preserved EF, when compared to low EF group. LRA showed that presence of anemia [ß=1.62; 95% CI 0.08-3.15; p=0.039)] and severe mitral regurgitation (ß=2.55; 95% CI 0.06-5.05; p=0.045) and systolic blood pressure (ß=-0.03; 95% CI -0.06 - -0.002; p=0.039) and blood urea nitrogen (ß=0.034; 95% CI 0.006 - 0.06; p=0.016) were the independent predictors of length of stay. CONCLUSION: Underlying cardiovascular risk factors, comorbidities and precipitating pathologies were diverse and highlighted the inhomogeneous characteristics of AHF syndromes. However, in-hospital mortality was high and initial clinical presentation characteristics were significantly associated with in-hospital outcome.

The first case report of a metastatic myxoid liposarcoma invading the left atrial cavity and pulmonary vein.

Myxoid liposarcoma (MLS) is the most commonly encountered liposarcoma subgroup, accounting for about 50% of all cases. Metastatic MLS of the heart is extremely rare. Herein we describe for the first time metastasis of MLS to the left atrium and left upper pulmonary vein in a 54-year-old woman who was admitted with shortness of breath and cough persisting for 2 weeks. The patient reported that a total surgical excision of MLS of the left thigh followed by radiotherapy was performed 4 years ago. An emergency operation was performed due to rapidly progressive worsening of clinical condition and echocardiographic determination of left atrial mass protruding into the left ventricle and obstructing the mitral inflow throughout the diastole. The mass could not be totally excised because it was tightly adhered to the surrounding tissue. Postoperative magnetic resonance imaging (MRI) showed a 5 × 3 cm residual tumor deforming the posterior wall of the left atrium entirely and extending into the left upper pulmonary vein. Histopathological examination was consistent with MLS. In conclusion, considering probable cardiac metastasis in patients presenting with respiratory symptoms with medical history of soft tissue sarcomas would be life saving. The case is discussed, and a review of the literature in relation to the metastatic involvement of the heart by MLS is presented.

Analysis of 24-hour heart rate variations in patients with epilepsy receiving antiepileptic drugs.

OBJECTIVE: The goal of the study described here was to evaluate interictal heart rate variability (HRV) in young patients with epilepsy, a patient population in whom sudden unexpected death in epilepsy (SUDEP) is known to be more common. METHODS: Twenty-four-hour ambulatory ECG Holter recordings of 37 patients (15-40 years old) and 32 healthy controls were compared. RESULTS: All of the time domain indices (SDNN, SDANN, RMSSD, and HRV triangular index) were significantly suppressed (P<0.001), and there was a marked reduction in parasympathetic tone (reduced HF(nu,)P<0.001) and an increase in sympathetic tone (increased LF(nu) and LF/HF ratio, P<0.001) in the patient group. Stepwise linear regression analysis revealed that polytherapy and epilepsy duration >10 years were independent variables associated with a reduction in SDNN. CONCLUSION: Our data suggest that the major determinants of suppressed SDNN are polytherapy and epilepsy duration >10 years. Analysis of spectral measures of frequency domain indices suggests that an increased sympathetic tone in association with a decreased parasympathetic tone may constitute the mechanism underlying SUDEP in young people with epilepsy.

Anthropometric indexes, insulin resistance, and serum leptin and lipid levels in women with cryptogenic epilepsy receiving topiramate treatment.

We aimed to investigate the effects of topiramate monotherapy on anthropometric indexes, insulin resistance, and serum leptin and lipid levels in 33 premenopausal women (mean age+/-standard deviation: 26.7+/-7.1years) with cryptogenic epilepsy. Body mass index (BMI), waist circumference and serum leptin, insulin and lipid levels were measured at baseline and at 6months after initiation of topiramate. We found reductions in BMI (p<0.001), waist circumference (p<0.001) and serum high-density lipoprotein (HDL) cholesterol levels (p=0.011). We also found significant improvements in insulin resistance (p=0.023), but not in serum leptin levels (p=0.45). Our results suggest that topiramate treatment in women with epilepsy is associated with reduced BMI and waist circumference and improvement in insulin resistance; however, according to our data, topiramate treatment is also associated with lower HDL cholesterol levels, which may substantially increase vascular disease.

Evaluation of cardiac repolarization indices in well-controlled partial epilepsy: 12-Lead ECG findings.

PURPOSE: To evaluate the cardiac repolarization indices in terms of QT intervals in patients with well-controlled partial epilepsy. METHODS: Seventy-six adult patients with well-controlled partial epilepsy and 66 healthy controls were enrolled into the study. 12-Lead ECGs were obtained from all participants. Corrected QT (QTc) intervals including maximum QTc (QTmaxc), minimum QTc (QTminc) and QTc dispersion (QTcd) were calculated. RESULTS: QTmaxc and QTcd intervals were significantly longer in the epilepsy group when compared to control group (439+/-27 ms vs. 422+/-25 ms, p<0.001 and 55+/-18 ms vs. 41+/-18 ms, p<0.001). The proportion of patients with pathologically prolonged QTcd intervals (>50 ms) was significantly higher in the epilepsy group (25 of 76 vs. 7 of 66, p=0.002). QTmaxc was significantly correlated with age (beta=0.29, p=0.012) after adjusting for gender, body mass index and duration of epilepsy. No correlation was observed between the duration of epilepsy and any of the QT intervals. There were no significant differences between the subgroups regarding QT intervals according to the etiology of the seizures (symptomatic/cryptogenic), being on mono- or polytherapy and treatment regimens (carbamazepine/non-carbamazepine). CONCLUSION: The results highlight the importance of cardiac evaluation even in patients with well-controlled epilepsy. 12-lead ECG recordings might help to uncover serious cardiovascular events.

Acute occlusion of the left main trunk presenting as ST-elevation acute coronary syndrome.

Acute obstruction of the left main coronary artery (LMCA) is not frequently encountered. Electrocardiographic findings are important to early diagnosis in determining an acute obstruction of the LMCA, which requires immediate aggressive treatment, in this extremely unstable condition. However, there is no single typical electrocardiographic pattern representing acute occlusion of the LMCA. We describe a rare electrocardiographic finding that suggested ST-elevation acute coronary syndrome of the anterior zone due to left main trunk total occlusion.