Gokhan Altunbas

Benefits of cardiac sonography performed by a non-expert sonographer in patients with non-traumatic cardiopulmonary arrest.

UNLABELLED The purpose of this study was to evaluate a rapid cardiac ultrasound assessment performed by trained non-expert sonographers integrated into the advanced cardiac life support (ACLS). MATERIAL AND METHODS This study was prospectively performed in 179 patients (104 males and 75 females) who underwent cardiopulmonary resuscitation (CPR) in an emergency department (ED) during two calendar years (2013 and 2014). Two senior doctors, who had received emergency cardiac ultrasonography training, performed cardiac ultrasound through the apical, subxiphoid, or parasternal windows. Ultrasound evaluation and pulse controls were performed simultaneously. SPSS 18.0 was used for statistical analysis. RESULTS A total of 63.7% (114) of the cardiopulmonary arrest incidents occurred out of the hospital. Only 13 patients had a femoral pulse during the initial evaluation, while 166 showed no femoral pulse. Initial monitoring showed a regular rhythm in 53 patients, ventricular fibrillation in 18 patients, and no rhythms in 108 patients. The first evaluation with ultrasound detected an effective heart rate in 26 patients and ventricular fibrillation in 14 patients, while no effective heart rate was observed in 139 patients. In addition, ultrasound revealed pericardial tamponade in seven patients and right ventricular enlargement in four cases. Global hypokinesia was detected in four patients and hypovolemia was observed in another four patients. CONCLUSION The use of real-time ultrasonography during resuscitation with real-time femoral pulse check can help facilitate the distinguishing of pea-type arrest, ascertain the cause of the arrest, infer a suitable treatment, and optimize medical management decisions regarding CPR termination.

Giant Pulmonary Artery Aneurysm: 12 Years of Follow-up. Case Report and Review of the Literature

Pulmonary artery aneurysm (PAA) is defined as pulmonary artery diameter of greater than 4 cm. PAA is not frequently encountered in clinical practice. There is a rare report in giant low-pressure PAA in terms of long-term follow-up. Herein, we sought to report a case of idiopathic PAA that was followed for 12 years in view of its learning points and to review the current literature for PAA. Herein we observed learning points according to long-term follow-up of PAA case as follows. PAA progressed dramatically after reaching a diameter greater than 6 cm and resulted in 7.87 cm in 2 years according to our case observation. Pericardial effusion may develop after a dramatic increase of PAA diameter. The reason for pericardial effusion is not always dissection or rupture; the presence of pericardial effusion possibly stemmed from the impairment of lymphatic drainage because of pressure effect on lymphatic circulation. Progressive increase of dilatation may lead to cough, as in our case.

Extensive vascular and valvular involvement in Gaucher disease

A 17-year-old patient with type III Gaucher disease was hospitalized for recurrent syncope. Echocardiography showed calcified aortic and mitral stenosis. Three-dimensional computed tomography showed severely calcified plaques on the ascending aorta, arcus, and abdominal aorta. On follow-up, palpitations and syncope were triggered by emotional stress, followed by severe bradycardia that was resulted in cardiogenic shock; the patient died after 8 h despite all efforts. Gaucher disease should be kept in mind in the differential diagnosis of a young patient with extensive vascular and valvular calcification. Patients with symptomatic severe valvular disease must be referred for early surgery.

Contribution of giant aneurysm of a membranous ventricular septal defect to right ventricular outflow tract obstruction.

Perimembranous defects are the most common types of ventricular septal defects (VSDs). In many cases, an aneurysm accompanies this defect. The aneurysm can have advantageous consequences on defect hemodynamics. However, it also has numerous complications that are frequently encountered in clinical practice. In this case, we describe a patient with a membranous VSD with giant aneurysm formation contributing to subpulmonic severe obstruction.

An iatrogenically unmasked life threatening disease: brugada syndrome.

Brugada syndrome is a life threatening disease that is usually overlooked during emergency service admissions. It is characterized by typical electrocardiography resembling right bundle branch block, static or dynamic ST-segment elevation in leads V 1-3. There is familial tendency in some cases. A majority of patients have a structurally normal heart and are likely to remain asymptomatic, however they may present to emergency departments with syncope and various serious arrhythmias. Therefore it is crucially important for emergency medicine physicians not to omit this potential diagnosis. Herein we report a case with Brugada syndrome which was iatrogenically unmasked after propafenone administration for atrial fibrillation.

Impact of Severe Mitral Stenosis on Visual Acuity, Intraocular Pressure, and Retinal Arteries

Impact of Severe Mitral Stenosis on Visual Acuity, Intraocular Pressure, and Retinal Arteries We sought to determine the impact of severe mitral stenosis (MS) on visual acuity and intraocular pressure, and also we searched for silent retinal artery emboli.

Early repolarization pattern in the coronary slow flow phenomenon

Abstract Background. The coronary slow flow phenomenon (CSFP) is well-documented, and the early repolarization pattern (ERP) has recently been shown to be a risk factor for the development of malignant ventricular arrhythmias. Methods. Those with true CSFP were included as cases and those with normal angiograms were included as controls. We assessed J-point elevation on surface electrocardiograms (ECGs) and defined ERP as notching or slurring of the terminal portion of the QRS takeoff. Results. We enrolled 115 cases (33 females, 82 males; mean age, 51.9 ± 11.5 years) and 45 controls (13 females, 32 males; mean age, 50.8 ± 11.7 years). ERP was more common among cases than among controls (65% vs. 28%, p = .001). Compared with the controls, cases were more likely to have J-point elevation in the inferior leads (25% vs. 13%, p = .002), in the D1 to aVL leads (22% vs. 15%, p = .001), and in the lateral leads (17.3% vs. 0%), p = .001). Notching was also significantly more common in cases than in controls (26.0% vs. 2.2%, p = .0001). Finally, concave/ascendant ST segment (33.9% vs. 5.2%, p = .006), horizontal/non-ascendant ST segment (14.7% vs. 1.7%, p = .054), and horizontal/non-ascendant ST segment and notching (15.6% vs. 2.2%, p = .012) patterns were more common in cases than in controls. Conclusions. We report that CSFP is associated with J-wave and slurring ERPs. However, the clinical significance of these changes needs to be clarified.

Ultrasound Guided Compression for Iatrogenic Femoral Artery Pseudo Aneurysms

To the Editor: Despite increasing use of radial artery for percutaneous interventions, femoral artery is still commonly used for both diagnostic and therapeutic interventions. Decreased size of sheats is the principal mechanism underlying reduced complication rates for femoral artery interventions. The most common accesserelated complications after femoral artery interventions are pseudoaneurysms, hematoma, arteriovenous fistula, and retroperitoneal hemorrhage. Pseudoaneurysms are frequently due to lower puncture below the common femoral artery bifurcation. The frequency is reported between 0.2% after diagnostic procedures and nearly 8% after interventional procedures. In our institution, we perform nearly 2,400 diagnostic and interventional procedures using femoral access. In the last 2 years, we experienced 16 cases of femoral pseudoaneurysms following femoral access. This makes nearly 0.003%. We did not perform routine ultrasonography, and thus, this ratio is not comparable to other studies. What we would like to underscore is 15 out of 16 cases (93.7%) were successfully treated with ultrasoundguided compression and only 1 patient underwent surgery who had a 25-mm pseudoaneurysm. Minimal and maximal duration of compression was 15 min and 3 hr, respectively. Before compression, intravenous line was established, skin was sterilized, and topical lidocaine was applied in order to reduce pain. Ultrasound-guided thrombin injection is another alternative method for treatment of femoral artery pseudoaneurysms. By using both manual compression and ultrasound-guided thrombin injection, Dzijan-Horn et al. reported a success rate of 97.2%. In their series, only 10 patients out of 432 pseudoaneurysm cases (2.3%) needed surgical intervention. In conclusion, ultrasound-guided compression is still an effective method for the treatment of iatrogenic femoral artery pseudoaneurysms.

Typical pericarditis ECG findings after falling from height. The PR segment depression or ST segment elevation

Acute pericarditis (AP) following blunt thoracic trauma is rare and difficult to diagnosis. A 43-year-old man with offered to the emergency department (ED) after falling from height before a week ago. The ECG performed in the ED was abnormal, ECG revealed PR segment depression in leads DII, DIII, aVF, and V3-6 and a preliminary diagnosis of acute inferolateral STEMI was presumed. Patients have evidence of systemic inflammation, including leukocytosis, elevated erythrocyte sedimentation rate. We are reporting a case of post-traumatic acute pericarditis presenting with PR-segment depression and normal cardiac enzymes mimicking acute STEMI.

Ventricular repolarization disturbances after high dose intravenous methylprednisolone Theraphy

OBJECTIVE There are no randomized trials evaluating the effects of pulse steroid treatment on cardiac electrophysiologic functions. The data are limited only to case series. In this study, we sought to evaluate the effects of high dose intravenous methylprednisolone therapy on indices of ventricular repolarization. METHODS Fifty patients with various autoimmune and inflammatory disorders were enrolled to the study. Electrocardiography (ECG) was obtained 4h before and 12h after the pulse steroid treatment. All ECGs were thoroughly evaluated by an experienced electrophysiologist. Indices of ventricular repolarization including QTc, JT, Tp-Te, Tp-Te/QTc were measured and compared with before and after-treatment ECGs. RESULTS There were 36 female and 14 male patients. Mean age was 36±13years. Heart rate was significantly reduced after the therapy (87,16±17,45bpm vs 73,86±17,45 p:0,001). QT interval (361,0±29,91 vs 388,20±42,84 p:0,001) and corrected QT interval (QTc) was significantly prolonged (401,60±19,79 vs 413,72±26,38 p:0,01) after pulse steroid therapy. Also, JT interval (273,0±28,73 vs. 299,60±45,66 p:0,001) and JT interval index (JTI%) was significantly prolonged (118,18±17,54 vs. 110,56±13,92 p:0,01). Tp-e interval was significantly prolonged after high-dose steroid treatment (74,60±13,12 vs. 83,80±13,68 p:0.001). The ratio of Tp-Te to QTc was also significantly increased after pulse steroid therapy (0,18±0,03 vs 0,20±0,03 p:0,009). CONCLUSION Our study shows that indices of ventricular repolarization are significantly prolonged after pulse steroid treatment. These findings indicate an increased risk of arrhythmias related to high dose intravenous methylprednisolone therapy.