Asymptomatic Tricuspid Stenosis Following a Complex Lead Extraction Procedure.

The number of transvenous extraction procedures for leads of intracardiac rhythm devices increased recently and the most common reason for lead extraction is device infection. In some cases, combined use of two different techniques is necessary. Long-term results of this approach are not clear. In this case report, we present a patient with biventricular implantable cardioverter defibrillator who underwent percutaneous hardware removal due to recurrent pacemaker pocket infections. Mechanical dilator sheath removal and Needle's Eye Snare were used in the same patient. Although asymptomatic, tricuspid stenosis was detected three years after the operation.

The evaluation of subcutaneous and visceral adipose tissue changes by computed tomography in coronavirus disease 2019 and comparison with quantitative analysis of lung involvement.

BACKGROUND: This study aims to reveal the relationship between lung involvement and visceral adipose tissue changes between chest-computed tomography (CT) scans taken in short intervals in COVID-19 patients. METHODS: The retrospective study included 52 patients who tested positive for SARS-CoV-2. All patients had two chest CT exams. Lung involvement measurements were calculated by using an artificial intelligence tool. Visceral and subcutaneous fat tissue was measured at the level of the first lumbar vertebra on chest CT. Additionally, demographic and laboratory data were collected. RESULTS: 52 patients were included (36.5 % female, mean age 50). Visceral fat area and visceral fat thickness changes were significantly positive predictors of total lung involvement changes (p=0.033, p=0.00024). Subcutaneous fat area and subcutaneous fat thickness changes were not associated with lung involvement change (p>0.05). CRP, IL-6, d-dimer, and ferritin levels were higher in patients who need intensive care units. CONCLUSION: Visceral adipose tissue changes may indicate that it can have a role as a reservoir of virus involvement.

Valvular heart disease: plasma B-type natriuretic peptide levels in patients with pure rheumatic mitral stenosis.

OBJECTIVE: Our study is designed to evaluate the plasma BNP levels in patients with pure MS and its possible correlation with clinical and echocardiographic parameters of the disease. METHODS AND RESULTS: The study included 29 patients (27 women, 2 men, mean age 43.4 +/- 11.8 y) with pure mitral valve stenosis in sinus rhythm and 24 age- and gender-matched healthy voluteers (17 women, 7 men, mean age 42 +/- 13 y). Plasma BNP levels were significantly higher in the mitral stenosis group compared to controls (91.1 +/- 69.6 pg/ml vs. 14.4 +/- 9.2 pg/ml, P < 0.0001). In univariate analysis, plasma BNP levels correlated positively with left ventricular end-systolic diameter (r = 0.439, P = 0.041), left atrial diameter (r = 0.772, P < 0.001), peak diastolic transmitral gradient (r = 0.621, P = 0.003), mean diastolic transmitral gradient (r = 0.751, P < 0.001), peak systolic pulmonary artery pressure (r = 0.467, P = 0.044), functional capacity (r = 0.819, P < 0.001) and negatively with left ventricular ejection fraction (r = -0.482, P = 0.020) and planimetric mitral valve area (r = -0.494, P = 0.006). No significant correlation existed between age, end-diastolic diameter and right ventricular diameter (r = 0.185, P = 0.337; r = 0.227, P = 0.309; r = 0.319, P = 0.092; respectively). A receiver operating characteristic (ROC) curve identified a BNP value of 32 pg/ml as the best cut-off for the identification of patients with mitral stenosis with a positive predictive value of 100% and a negative predictive value of 75%. CONCLUSIONS: In this study we found elevated plasma BNP levels in patients with pure MS in sinus rhythm. Plasma BNP levels correlated with disease severity and this can have potential clinical implications, for example in patients undergoing percutaneous balloon mitral valvuloplasty or in patients with poor echocardiographic windows.

The predictive value of QRS duration in response to levosimendan therapy in patients with decompensated heart failure.

PURPOSE: We aimed to investigate the role of QRS duration on the surface electrocardiogram (ECG) in predicting response to levosimendan therapy in patients with acute systolic heart failure. METHODS: Patients with an ejection fraction (EF) lower than 35% who required intravenous inotropic support despite optimal heart failure therapy were included in this study. Patients were divided into two groups according to QRS durations on ECG. Group 1 (n=16) included patients with a QRS duration equal to or shorter than 120 ms and group 2 (n=14) included patients with a QRS duration longer than 120 ms. New York Heart Association (NYHA) functional class, plasma BNP levels and echocardiographic measurements were compared within and between groups before and after the infusion. RESULTS: In both groups statistically significant improvement was observed in NYHA class, plasma BNP levels and left ventricular end-systolic diameter after the levosimendan infusion compared to baseline (P < 0.025). In addition, in group 1 patients, left atrial diameter, left atrial volume, left ventricular end-diastolic diameter, left ventricular end-diastolic volume, left ventricular end-systolic volume (LVESV), left ventricular EF, mitral E velocity, mitral annular Aa and Sa parameters improved after the infusion compared to the baseline values (P < 0.025). Comparison of both groups revealed improvement of NYHA class, an increase of left ventricular EF and a signficant decrease of LVESV after levosimendan in group 1 (P < 0.05). CONCLUSION: QRS duration on ECG may be used as a practical bedside indicator in estimating short-term response to levosimendan therapy.

Assessment of planimetric mitral valve area using 16-row multidetector computed tomography in patients with rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Transthoracic two-dimensional echocardiography (TTE) is currently the 'gold standard' for the evaluation of rheumatic mitral valve disease. Multidetector computed tomography (MDCT) is a promising technique for the evaluation of heart valves. The study aim was to evaluate the planimetry of the mitral valve area (MVA) with 16-row MDCT in comparison with TTE, in patients with rheumatic mitral stenosis. METHODS: Twenty-six patients (18 females, eight males; mean age 41.7 +/- 8.7 years) with rheumatic mitral valve disease, who had been referred for 16-row MDCT for various indications, such as evaluation of the coronary arteries, assessment of pulmonary vein anatomy before catheter ablation of paroxysmal atrial fibrillation, suspicion of aortic dissection or pulmonary embolism, were recruited. All patients were in sinus rhythm. The MDCT acquisition was performed using a 16-row scanner. Echocardiographic planimetry of MVA was performed in the standard parasternal short-axis view within one week. RESULTS: Planimetry of the MVA with MDCT did not differ from that with TTE (1.88 +/- 0.46 cm2 versus 1.83 +/- 0.50 cm2, p = 0.242), and there was an excellent correlation between two techniques (r = 0.923, p < 0.0001). Seven patients had calcific mitral valves (mean calcium score 216.8 +/- 783.8 Agatston units). In these patients, MVA measured by MDCT was 1.73 +/- 0.39 cm2 and by TTE planimetry was 1.72 +/- 0.54 cm2 (p = 0.866; r = 0.963, p = 0.0005). When using the pressure half-time (PHT) method, the MVA was obtained in 24 of the 26 patients. MVA by PHT did not differ from the MVA calculated by TTE planimetry, nor from that obtained with MDCT planimetry (1.79 +/- 0.46 cm2 versus 1.81 +/- 0.51 cm2, p = 0.427 and 1.79 +/- 0.46 cm2 versus 1.86 +/- 0.48 cm2, p = 0.101, respectively). The correlation coefficient for the MDCT-derived MVA and PHT-derived MVA was 0.8969 (p < 0.0001). Although not statistically significant, in nine patients with moderate to severe mitral stenosis (MVA < 1.5 cm2), the MDCT tended to overestimate MVA compared to echo planimetry (1.35 +/- 0.19 cm2 versus 1.28 +/- 0.21 cm2, p = 0.059). CONCLUSION: MDCT enabled accurate planimetry of the MVA in patients with rheumatic mitral stenosis, in comparison with TTE.

Left ventricular noncompaction associated with a sinoatrial node artery originating from the posterolateral branch of the right coronary artery.

Noncompaction of the ventricular myocardium (NVM) is a rare unclassified cardiomyopathy which is characterized by multiple prominent trabeculations and deep intertrabecular recesses. This cardiomyopathy can be isolated or in combination with other congenital cardiac disorders, including coronary artery abnormalities. A 56-year-old female patient presented to the cardiology department with complaints of exertional dyspnoea and chest pain. Transthoracic echocardiography revealed left ventricular dilatation with diffuse hypokinesis. Multiple prominent trabeculations with deep inter-trabecular recesses were observed at the left ventricular apex. Also, coronary angiography demonstrated a sinoatrial node artery originating from the posterolateral branch of the right coronary artery.

A case of systemic lupus erythematosus presenting with hypereosinophilia and Loeffler endocarditis.

A 15-year-old boy who was admitted to the neurology department had multiple cerebral infarcts on cranial magnetic resonance imaging. A transthoracic echocardiogram revealed myocardial thickening and apical thrombus in the left ventricle suggesting Loeffler endocarditis. There was remarkable hypereosinophilia on the haemogram. An investigation for the aetiology of hypereosinophilia led to the diagnosis of systemic lupus erythematosus and associated antiphospholipid syndrome. This case represents a very rare case of systemic lupus erythematosus in which the initial presentation was hypereosinophilia related Loeffler endocarditis.

Single coronary artery arising from the right sinus of Valsalva.

Single coronary artery (SCA) is a rare congenital anomaly in which the entire coronary system arises from a solitary ostium. A 65-year-old male with a history of diabetes mellitus, hypertension, and hyperlipidemia was admitted with exertional angina pectoris of new onset. His physical examination, hemogram, thyroid function tests, chest X-ray, electrocardiogram, and transthoracic echocardiogram were normal. In treadmill exercise test, the patient could not reach submaximal heart rate due to fatigue. Coronary angiography revealed an SCA arising from the right sinus of Valsalva (type R-IIA). The left coronary artery (LCA) coursed anteriorly in front of the right ventricular outflow tract and gave off branches for the left anterior descending and left circumflex (LCx) arteries. A mild diffuse nonobstructive atherosclerotic lesion was also detected in the LCx. The entire SCA and the anterior course of the LCA in relation to the great vessels were further displayed by 16-row multislice computed tomography. The atherosclerotic lesion was not eligible for percutaneous intervention and the patient was scheduled for medical therapy with recommendation of risk factor modification.

Acute type A aortic dissection with diastolic prolapse of intimal flap into the left ventricle.

A 45-year-old man presented to the emergency department with acute oppressive chest pain. On physical examination, a loud decrescendo diastolic murmur of grade 2-3/6 was audible on the left sternal edge. The electrocardiogram was within normal limits and there were no signs of myocardial ischemia. Transthoracic echocardiography revealed an acute type A aortic dissection with an intimal flap prolapsing into the left ventricular outflow tract through the aortic valve during diastole. Color Doppler examination showed severe aortic regurgitation of grade 3. The aortic valve had three leaflets with normal thickness. Aortic diameter was 50 mm at the sinus of Valsalva and 66 mm after the sinotubular junction. The left and right ventricles were normal in size and function. Dynamic thorax and abdominal computed tomography demonstrated that the dissection flap extended from the ascending aorta to the proximal segments of the common iliac arteries. The patient underwent successful ascending aorta replacement with preservation of the aortic valve.

A rare complication of radiofrequency catheter ablation of left atrial tachycardia: atrial septal dissection and left atrial hematoma formation.

A 52-year-old man with left atrial tachycardia underwent radiofrequency catheter ablation. A steerable 4-mm-tip ablation catheter was advanced into the left atrium through a patent foramen ovale without transseptal puncture. However, the tip of the catheter was stuck in a structure. A pull-back maneuver rendered the catheter free and the procedure was cancelled. Transthoracic and transesophageal echocardiograms obtained immediately after the procedure showed intimal layer dissection in the interatrial septum and intramural hematoma formation throughout the anterior left atrial wall. The patient was in stable condition. Therefore, he was followed-up conservatively with serial echocardiographic examinations. The dissected intimal layer disappeared in 10 days and the hematoma underwent near-complete resolution in three months. This case highlights a rare complication of catheter ablation procedure that all interventionists should be familiar with.

[Thrombosed giant proximal pulmonary artery aneurysm]. / Trombozlu dev proksimal pulmoner arter anevrizmasi.

We present a 36-year-old male patient with a previous diagnosis (22 years) of Eisenmenger's syndrome, who had a giant proximal pulmonary artery aneurysm complicated by massive thrombus formation. The patient experienced paroxysmal atrial fibrillation attacks for the past month. His functional capacity was New York Heart Association class III. Chest radiography showed aneurysmal dilatation in the left pulmonary artery. The patient was assessed by transthoracic echocardiography and multislice computed tomography. There was mild narrowing in the thick and calcified pulmonary valve (peak systolic gradient 35 mmHg) and moderate regurgitation. The mean pulmonary artery pressure was estimated as 50 mmHg. The diameters of the main, left, and right pulmonary arteries were 6.5 cm, 10 cm, and 3.7 cm, respectively. There was a massive thrombus in the aneurysmatic left pulmonary artery. The patient was referred to the cardiovascular surgery department for pulmonary artery reconstruction and cardiopulmonary transplantation. In addition, medical treatment was instituted with warfarin for thrombus and paroxysmal atrial fibrillation, metoprolol for atrial fibrillation, and bosentan for pulmonary hypertension. The patient's functional capacity showed improvement after the first month of medical treatment and no complications were seen within a year follow-up.

[Ablation of right ventricular outflow tract tachycardias under guidance of noncontact mapping system]. / Sag ventrikül çikis yolu tasikardilerinin temassiz haritalama sistemi kilavuzlugunda ablasyonu.

OBJECTIVES: We evaluated the efficiency of noncontact mapping, a new mapping technique, for the catheter ablation of right ventricular outflow tract tachycardias. STUDY DESIGN: The study included 13 symptomatic patients (4 males, 9 females; mean age 39+/-15 years) with a structurally normal heart, who had sustained ventricular tachycardia (VT) or nonsustained VT with ventricular premature beats (VPB), all arising from the right ventricular outflow tract. For noncontact mapping-guided (EnSite) ablation, first right ventricular geometry was reconstructed. Then, voltage maps of the right ventricle were obtained during sinus rhythm and tachycardia (or ectopic) beats. Index arrhythmia was induced in the form of sustained VT in three patients, and nonsustained VT or VPB in 10 patients. Radiofrequency was applied to endocardial foci of tachycardia beats using a standard, 4-mm ablation catheter. RESULTS: The endocardial breakthrough sites of the beats were the posterior septum in seven patients, anterior septum in four patients, and posterior free wall in two patients. A mean of 25 (range 7 to 45) radiofrequency current deliveries were applied to the target sites. The mean procedure time was 190 minutes. Index arrhythmia was eliminated in 10 patients after the procedure. No serious complications occurred during or after the procedure. CONCLUSION: Our experience with radiofrequency ablation of right ventricular outflow tract tachycardias under noncontact mapping guidance shows that this procedure can be performed efficiently and safely in our country.

Plasma brain natriuretic peptide levels in patients with rheumatic heart disease.

BACKGROUND: Brain natriuretic peptide (BNP) is a cardiac hormone secreted from the ventricular myocardium as a response to ventricular volume expansion and pressure overload. Rheumatic heart disease (RHD) is still an important cause of heart failure in developing countries. AIMS: To measure BNP levels in patients with RHD and to determine whether BNP concentrations correlate with clinical and echocardiographic findings. METHODS: Eighty-eight patients with rheumatic valve disease and 24 age- and sex-matched healthy subjects were entered in the study. BNP was measured using the Triage B-Type Natriuretic Peptide test (Biosite Diagnostics, San Diego, CA). Transthoracic echocardiography was performed in all patients to assess the severity of the valve disease and for the measurement of pulmonary artery pressure. RESULTS: The plasma concentrations of BNP were significantly higher in patients with rheumatic heart disease than in control subjects (232+/-294 vs. 14+/-12 pg/ml, p<0.0001). The plasma BNP level was significantly higher in NYHA class III+IV than in class II (463+/-399 vs. 192+/-243 pg/ml, p<0.0001) and in NYHA class II than in class I (192+/-243 vs. 112+/-135 pg/ml, p<0.001). The independent determinants of higher BNP levels were NYHA functional class and systolic pulmonary artery pressure in multivariate analysis. CONCLUSION: We found increased plasma BNP levels in patients with rheumatic heart disease compared with healthy subjects.

Increased levels of high sensitive C-reactive protein in patients with chronic rheumatic valve disease: evidence of ongoing inflammation.

The precise pathogenetic mechanism(s) of rheumatic fever and rheumatic heart disease have never been defined. C-reactive protein (CRP) is increased in patients with acute rheumatic fever, but it is not known whether plasma levels increase in patients with chronic rheumatic valve disease. The aim of this study was to determine the role of inflammation detected by high sensitivity CRP (hs-CRP) levels in the progression of chronic rheumatic valve disease. A total of 113 patients with chronic rheumatic valve disease (81 women, 32 men; mean age 40+/-14 years, range 13-70), 51 patients with prosthetic valve(s) (31 women, 20 men; mean age 48+/-13 years, range 21-71) and 102 healthy subjects (68 women, 34 men, mean age 41+/-12 years, range 25-73), as a control group, were assessed. Patients with acute rheumatic fever, acute infection, inflammatory disease, malignancy, acute myocardial infarction and trauma were excluded. hs-CRP was determined using latex-enhanced immunonephelometric assays on a BN II analyzer (Behring). Transthoracic echocardiography was performed in all patients in order to evaluate valvular disease. Levels of hs-CRP were significantly higher in patients with chronic rheumatic heart disease than in patients with prosthetic valve(s) and healthy subjects (0.62+/-0.64 vs. 0.35+/-0.41 vs. 0.24+/-0.18 mg/l, P<0.01 and P<0.001 respectively). No correlation was observed between CRP and age, sex or functional capacity. We found that hs-CRP is increased in chronic rheumatic heart disease; this may indicate that inflammatory response still persists in the chronic phase.

Effect of left ventricular diastolic dysfunction on left atrial appendage function and thrombotic potential in nonvalvular atrial fibrillation.

OBJECTIVE: We aimed to investigate effects of left ventricular diastolic dysfunction on left atrial appendage functions, spontaneous echo contrast and thrombus formation in patients with nonvalvular atrial fibrillation. METHODS: In 58 patients with chronic nonvalvular atrial fibrilation and preserved left ventricular systolic function, left atrial appendage functions, left atrial spontaneous echo contrast grading and left ventricular diastolic functions were evaluated using transthoracic and transoesophageal echocardiogram. Patients divided in two groups: Group D (n=30): Patients with diastolic dysfunction, Group N (n=28): Patients without diastolic dysfunction. Categorical variables in two groups were evaluated with Pearson's chi-square or Fisher's exact test. The significance of the lineer correlation between the degree of spontaneous echo contrast (SEC) and clinical measurements was evaluated with Spearman's correlation analysis. RESULTS: Peak pulmonary vein D velocity of the Group D was significantly higher than the Group N (p=0.006). However, left atrial appendage emptying velocity, left atrial appendage lateral wall velocity, peak pulmonary vein S, pulmonary vein S/D ratio were found to be significantly lower in Group D (p=0.028, p<0.001, p<0.001; p<0.001). Statistically significant negative correlation was found between SEC in left atrium and left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities respectively (r=-0.438, r=-0.328, r=-0.233, r=-0.447). Left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities were significantly lower in SEC 2-3-4 than SEC 1 (p=0.003, p=0.029, p<0.001, p=0.002). CONCLUSION: In patients with nonvalvular atrial fibrillation and preserved left ventricular ejection fraction, left atrial appendage functions are decreased in patients with left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction may constitute a potential risk for formation of thrombus and stroke.

Multidetector computed tomographic anatomy of the coronary sinus in patients with supraventricular reentrant tachycardia.

BACKGROUND: In a number of previous studies it has been observed that coronary sinus (CS) ostium was larger and cannulation was easier in patients with atrioventricular nodal reentrant tachycardia (AVNRT). AIM: To investigate the size and morphology of CS in AVNRT patients and compare them to those of atrioventricular reentrant tachycardia (AVRT) patients and a control group using multidetector computed tomography (MDCT), which is a non-invasive technique. METHODS: Eighteen consecutive patients with AVNRT who were scheduled for catheter ablation in our institution constituted the study population. Sixteen patients with AVRT and 16 patients without supraventricular arrhythmia who underwent MDCT for other indications comprised the control group. A conventional transthoracic echocardiography was performed to all patients. The diameter of the CS at ostium as well as at 5, 10, and 15 mm inside the CS were measured on MDCT images. The CS was also categorised according to its morphology, as to whether it had a windsock shape or a tubular shape. RESULTS: The AVNRT, AVRT and control groups were similar with regard to age, gender, body surface area and echocardiographic parameters. The size of the CS ostium was 10.9 ± 3.0, 11.1 ± 3.9 and 12.5 ± 3.6 mm for the AVNRT, AVRT and control groups, respectively (p = 0.393). There was no significant difference in the size of the CS from the ostium until 15 mm into the CS between the AVNRT, AVRT and control groups. The number of patients with windsock or tubular CS morphology were also similar between the three groups. CONCLUSIONS: Contrary to previous reports, the CS size and morphology of patients with AVNRT did not differ from that of AVRT or control patients.

Arrhythmias during and after zoledronic acid infusion patients with bone metastasis.

Zoledronic acid (ZA) is one of the important bisphosphonates which is widely used in bone metastatic cancer and osteoporotic patients. In a few studies, it has been reported that treatment with bisphosphonates was associated with an increased risk of atrial fibrillation. We aimed to evaluate the arrhythmias that developed during and immediately after infusion of the ZA. Fifty-two bone metastatic patients were included in the study group. All patients had 24-h Holter monitorization during the first dose ZA infusion day. All of the patients had 4-h basal cardiac rhythm records before ZA infusion and about 19 h after infusion. A short survey including demographic data and past medical history has been completed. None of patients had clinically important arrhythmias before ZA infusion. We divided arrhythmias into two groups as supraventricular and ventricular. We evaluated arrhythmias in pre-infusion, during infusion, and post-infusion periods. ZA was administered 4 mg intravenously (IV) in 15 min. Thirty-three of patients (63.5 %) were male and 19 (36.5 %) patients were female. Mean age of the patients was 53.9 ± 11.8 years. Most frequent cancers were breast (25 %) and lung cancer (15.3 %). Twelve (23 %) patients had history of mediastinal radiotherapy. In basal records, we detected that twenty-four (46 %) of patients had supraventricular premature complexes (SVPC) or ventricular premature complexes (VPC). Fifteen (28.8 %) of patients had SVPC and fourteen (26.9 %) had VPC during infusion period. After infusion period, 48 (92.3 %) of patients had SVPC and 41 (78.8 %) had VPC. Only 3 patients had no arrhythmia after infusion. Three patients had sinus arrhythmia and two had Mobitz type 2 atrioventricular blocks after infusion. One patient, who had no history of comorbidities and had SVPC in the basal records, developed atrial fibrillation that was refractory to medical cardioversion after 10 days of seventh dose of ZA infusion. In this study, we found that both SVPC and VPC increased in cancer patients treated with ZA. Furthermore, ZA may induce clinically important arrhythmias.

Zolmitriptan-induced acute myocardial infarction.

Triptans are an established treatment for acute migraine attacks. By activating 5HT1B/1D receptors they lead to vasoconstriction of the cerebral blood vessels which are dilated during migraine attacks. Moreover, they reduce secretion of vasoactive peptides and conduction of pain stimuli over the cerebral cortex. In up to 7% of cases of treatment with triptans, thoracic pain occurs, although this is mostly transient, mild and without lasting ischemia. We present the case of a 45 year-old woman with a history of migraine with visual aura since the age of 20. She had no history of diabetes mellitus, hypertension, smoking or any other risk factors for cardiovascular events before she was admitted to our emergency room with typical chest pain. An electrocardiogram revealed anterior myocardial infarction following her monthly dose of oral zolmitriptan. Catherization revealed a normal coronary arterial system. The laboratory indices for cardiac risk were within normal ranges. The patient was advised to avoid triptans permanently on being discharged.