Ibrahim Marai

Coexistence of thyroid autoimmunity with other autoimmune diseases: friend or foe? Additional aspects on the mosaic of autoimmunity.

Autoimmunity encompasses a wide spectrum of diseases from organ-specific diseases like Hashimoto thyroiditis, to systemic diseases such as systemic lupus erythematosus. These diseases are characterized by inflammation and the production of a wide range of autoantibodies directed against multiple autoantigens. Although their etiology is still poorly understood, genetic, immunological, hormonal, and environmental factors are major predisposing and triggering factors. These multiple factors, like pieces in a mosaic, may interplay in different forms, leading to the expression of various autoimmune manifestations and diseases. This phenomenon, which has been referred by us as the “mosaic of autoimmunity”, illuminates the diversity of autoimmune manifestations among susceptible individuals. From this theoretical framework we conducted a wide search of the literature, on the prevalence of thyroid autoimmunity, the commonest of the autoimmune conditions, among other autoimmune diseases, and discuss the possible clinical significance of this association.

Improvement of Congestive Heart Failure by Upgrading of Conventional to Resynchronization Pacemakers

Aims: To compare the clinical response of patients with right ventricular apical pacing (RVAP) upgraded to cardiac resynchronization therapy (CRT) to that of previously nonpaced heart failure (HF) patients who had de novo CRT implantation.

Anticardiolipin and anti-beta-2-glycoprotein I antibodies

The anticardiolipin (aCL) antibody test was first established in 1983, using cardiolipin (negatively charged phospholipid) as an antigen in a solid-phase immunoassy. It was first applied to the study of systemic lupus erythematosus patients, and was found associated with thromboses and recurrent pregnancy losses. The wide use of this test was determinant in the definition of the “aCL or antiphospholipid syndrome” (APS). Later, it was demonstrated that aCL antibodies do not recognize anionic phospholipids but are directed against plasma proteins bound to anionic phospholipids, mainly beta-2-glycoprotein I, which is now considered as the autoantigen in APS. Anti-beta-2-glycoprotein I (anti-β2GPI) is not yet accepted as a serological criterion for APS, but most investigators would consider a patient with anti-β2GPI antibodies and clinical features of APS to have the syndrome. aCL and anti-β2GPI are a heterogeneous group of antibodies with different clinical significances and can be present in different autoimmune diseases as well as in infectious diseases.

Acute ST elevation myocardial infarction during intravenous immunoglobulin infusion

Abstract:  Intravenous immunoglobulin (IVIG) preparations are increasingly being used in the treatment of autoimmune disorders. This treatment is regarded as generally safe, and most of the adverse effects associated with IVIG administration are mild and transient. This paper reports a 72‐year‐old patient with known ischemic heart disease admitted for a Guillain–Barré syndrome variant, who developed acute ST elevation myocardial infarction (MI) during the first hours of IVIG infusion. The literature on acute MI during IVIG treatment is reviewed. Evaluation of each patient for cardiovascular risk prior to IVIG treatment is recommended as is the assessment of risk versus benefit. If IVIG is prescribed, we propose close monitoring and slow infusion rate.

Novel Clinical Manifestation of the Known SCN5A D1790G Mutation.

The D1790G mutation was found in all 24 patients of an extended long QT family but not in 200 chromosomes carried by healthy individuals. We describe a 37-year-old man presenting with a typical spontaneous type 1 Brugada pattern who in electrophysiological testing had easily inducible ventricular fibrillation. At the age of 47 years he had an atrial ventricular type 2 block documented by an exercise test and a Holter monitor. Genetic analysis revealed a known D1790G mutation in the gene encoding of the sodium channel (SCN5A) that until now has been associated only with the long QT phenotype. Although this mutation has not been associated with a reduction of sodium channel expression, we hypothesize that sodium currents are further diminished due to the 20-mV shift of the steady-state inactivation curve, and this could contribute to the Brugada phenotype. This case is important as it allows a better understanding of the underlying molecular mechanisms of Brugada syndrome. Moreover, this observation raises concern about the safety of class IC drug therapy in long QT type 3 patients and quinidine therapy in Brugada patients, and emphasizes the importance of a thorough clinical and genetic evaluation.

Cryoablation for Ventricular Tachycardia Originating from Anterior Papillary Muscle of Left Ventricle Guided by Intracardiac Echocardiography

Papillary muscles (PMs) were reported to be origin of ventricular arrhythmia (VA). Radiofrequency (RF) ablation was reported to be acutely effective in eliminating VA. However, the recurrence rate is high. Recently, cryoablation guided by intracardiac echocardiography, 3-dimensional mapping system, and image integration was introduced as alternative strategy for this challenging ablation. We present a case of ventricular tachycardia originating from anterior PM of left ventricle treated by cryoablation guided only by intracardiac echocardiography.

Impact of computed tomography image and contact force technology on catheter ablation for atrial fibrillation

AIM To investigate the impact of using computed tomography (CT) and contact force (CF) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation (AF) ablation. METHODS This non-randomized study included 2 groups of patients. All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication. The first group included 33 patients who underwent circumferential pulmonary veins isolation (PVI) for AF during 2012 and 2013 guided by CT image integration (Cartomerge, Biosense Webster, Diamond Bar, CA, United States) of left atrium and pulmonary veins into an electroanatomic mapping (EAM) system (CT group) using standard irrigated radiofrequency catheter (ThermoCool, Carto, Biosense Webster, Diamond Bar, CA, United States) or irrigated catheter with integrated CF sensor (Smart Touch, Carto, Biosense Webster, Diamond Bar, CA, United States). The second group included immediately preceding 32 patients who had circumferential PVI by standard irrigated catheter (ThermoCool) using only EAM (Carto) system (EAM group). Linear lesions were performed according to the discretion of operator. RESULTS Sex, age, and persistent AF were not different between groups. PVI was achieved in all patients in both groups. Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups. Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group (81% vs 55%; respectively; P = 0.027). When 11 patients from CT group who had ablation using Smart Touch catheter were excluded, the difference between CT group and EAM became non significant (73% vs 55%; respectively; P = 0.16). Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using standard irrigated catheter during follow-up (100% vs 73%; respectively; P = 0.07). Major complications (pericardial effusion, cerebrovascular accident/transient ischemic attack, vascular access injury requiring intervention) did not occurred in both groups. CONCLUSION These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF.