İhsan Dursun

Late pacemaker twiddler syndrome

Dr. Ihsan Dursun, MD ()) · Prof. Osman Yesildag, FESC Korhan Soylu, MD · Prof. Ozcan Yilmaz · Erdogan Yasar, Tech Murat Meric, MD Ondokuz Mayis Universitesi Tip Fakultesi, Kardiyoloji Bolumu 55139 Kurupelit Samsun/Turkey Tel.: 90-5 32 / 4 30 87 62 Fax: 90-3 62 / 4 57 60 41 E-Mail: ihsandursun@mynet.com Sirs: Twiddler syndrome, known as the rolling up of the pacemaker battery within the pacemaker pocket, was first described in 1968 by Bayliss et al. [1]. Frequently, twisting of the pacemaker battery within the pacemaker pocket ends with the dislocation of the electrode, diaphragmatic stimulation and the loss of capture [2]. This situation is not limited to only cardiac pacemaker batteries. It has also been observed in implantable cardioverter defibrillators [3]. Symptoms begin with the twisting of the pacemaker battery within the pacemaker pocket in which it is implanted. The capture problem is a result of the dislocation of the electrode. Hypoperfusion symptoms such as fatigue, tiredness, confusion, presyncope and syncope can be observed if the patient is completely dependent on the cardiac pacemaker [4]. Except the symptoms related with the failure of the cardiac pacemaker, other symptoms are also observed frequently as well due to the damage of the neigbouring organs. Ipsilateral phrenic nerve stimulation concludes the sensation of the diaphragmatic and abdominal pulsations. Additionally, if the electrodes become more twisted around the battery, rhythmic arm movements can occur due to the stimulation of the brachial plexus [5]. However not all cases display clinical symptoms [3]. Capture or pace problems can also be observed in the electrocardiography (ECG). The ECG is also abnormal if the electrode dislocates intermittently. On a chest X-ray, the electrodes can be seen as bent, twisted or dislocated and fractured [4].

The relationship between dipper/nondipper pattern and cardioankle vascular index in hypertensive diabetic patients.

Objective24-h ambulatory blood pressure monitoring (24-h ABPM) is a better predictor of cardiovascular events (CVEs) than spot blood pressure (BP) measurements in hypertensive diabetic patients. In this patient group, the underlying mechanism of the relationship between a nondipper pattern determined with 24-h ABPM and increased incidence of CVE is unknown. Cardioankle vascular index (CAVI) is a new index of the overall arterial stiffness from the aorta to the ankle. The objective of the present study was to evaluate the relationship between a dipper/nondipper pattern and arterial stiffness in hypertensive diabetic patients using the CAVI method. MethodsWe enrolled 99 hypertensive patients with type-2 diabetes mellitus. 24-h ABPM and CAVI measurements were performed for all patients. The relationship between a dipper/nondipper pattern and CAVI measurements was analyzed. ResultsSixty-three (63.6%) patients had a nondipper pattern. In univariate analysis, CAVI, mean arterial pressure (MAP)-asleep, overall diastolic BP, overall systolic BP, duration of hypertension, and statin use were significantly higher among patients with a nondipper pattern than that in dippers. Multivariate linear regression analyses showed that the difference between MAP-asleep and MAP-awake was associated independently with CAVI (&bgr; coefficient=0.514, P<0.001). CAVI was correlated negatively with the nocturnal decrease in MAP (%) (r=−0.558 and P<0.001). ConclusionThe nondipper pattern determined with 24-h ABPM in hypertensive diabetic patients is associated with an increase in arterial stiffness. This patient group should be monitored closely for CVEs.

Value of coronary artery calcium score to predict severity or complexity of coronary artery disease

Background Prediction of severity or complexity of coronary artery disease (CAD) is valuable owing to increased risk for cardiovascular events. Although the association between total coronary artery calcium (CAC) score and severity of CAD, Gensini score was not used, it has been previously demonstrated. There is no information about the association between total CAC score and complexity of CAD. Objectives To investigate the association between severity or complexity of coronary artery disease (CAD) assessed by Gensini score and SYNTAX score (SS), respectively, and coronary artery calcium (CAC) score, which is a noninvasive method for CAD evaluation in symptomatic patients with accompanying significant CAD. Methods Two-hundred-fourteen patients were enrolled. Total CAC score was obtained before angiography. Severity and complexity of CAD was assessed by Gensini score and SS, respectively. Associations between clinical and angiographic parameters and total CAC score were analyzed. Results Median total CAC score was 192 (23.0-729.8), and this was positively correlated with both Gensini score (r: 0.299, p<0.001) and SS (r: 0.577, p<0.001). At multivariate analysis, it was independently associated with age (ß: 0.154, p: 0.027), male gender (ß: 0.126, p: 0.035) and SS (ß: 0.481, p< 0.001). Receiver-operating characteristic (ROC) curve analysis revealed a cut-off value > 809 for SS >32 (high SS tertile). Conclusion In symptomatic patients with accompanying significant CAD, total CAC score was independently associated with SS and patients with SS >32 may be detected through high Agatston score.

Presystolic A wave may predict increased arterial stiffness in asymptomatic individuals.

BackgroundStiffness of large arteries has been related to cardiovascular mortality. The cardioankle vascular index (CAVI) is a novel parameter of arterial stiffness. The main aim of the present study was to investigate the association between presystolic wave (PSW) on left ventricular outflow tract (LVOT) and CAVI. Patients and methodsPatients admitted to the cardiology outpatient clinic were consecutively enrolled. Arterial stiffness was assessed by the CAVI. It was measured using a VaSera VS-1000 CAVI instrument. Pulse Doppler flow evaluation in LVOT was performed just proximal to the aortic valve in an apical five-chamber view. The presence of a PSW preceding the LVOT flow was assessed in all patients. ResultsA total of 200 patients were enrolled consecutively. Patients with PSW had higher CAVI values compared with those without PSW (8.6±1.6 vs. 7.3±1.5). There was a significant correlation between PSW velocity and CAVI (r=0.34, P<0.001). Analysis using the receiver operating characteristics curve showed that PSW velocity of 61 cm/s constitutes the cutoff value for abnormal CAVI (CAVI≥9) with 75% sensitivity and 74% specificity (area under the curve: 0.883, 95% confidence interval: 0.694–0.972). ConclusionAssessment of presystolic A wave on echocardiography examination may provide important information on the vascular function, which has a prognostic impact.

Complexity of lower extremity peripheral artery disease reflects the complexity of coronary artery disease.

We investigated the relationship between peripheral artery disease complexity and coronary artery disease complexity in patients with peripheral artery disease. A total of 449 patients were enrolled. SYNTAX score, a marker of coronary artery disease complexity, was assessed by dedicated computer software and complexity of peripheral artery disease was determined by Trans Atlantic Inter-Society Consensus II classification. The SYNTAX score of patients with minimal peripheral artery disease, Trans Atlantic Inter-Society Consensus A, Trans Atlantic Inter-Society Consensus B, Trans Atlantic Inter-Society Consensus C and Trans Atlantic Inter-Society Consensus D were 5 (11), 12.5 (13.25), 20 (14), 20.5 (19) and 27.5 (19), respectively (values in brackets represent the interquartile range). SYNTAX score and Trans Atlantic Inter-Society Consensus class was moderately correlated (r = 0.495, p < 0.001). In multivariate regression analysis male sex (B = 0.169, p < 0.001, CI95% = 0.270–0.735), Log10 SYNTAX score (B = 0.282, p < 0.001, CI95% = 0.431–0.782), Log10 creatinine (B = 0.081, p = 0.036, CI95% = 0.043–1.239), low-density lipoprotein (B = 0.114, p = 0.003, CI95% = 0.001–0.006) and high-density lipoprotein (B = −0.360, p < 0.001, CI95% = −0.063 to −0.041) were the independent predictors of Trans Atlantic Inter-Society Consensus II class. We have shown that patients with complex peripheral artery disease had complex coronary artery disease.

Relationship between Nitrate-Induced Headache and Coronary Artery Lesion Complexity.

Objective: The aim of the present study was to investigate the association between nitrate-induced headache (NIH) and the complexity of coronary artery lesions in patients with stable coronary artery disease (CAD). Subjects and Methods: Two hundred and seventy-five patients with anginal chest pain who underwent coronary angiography were enrolled in the present study. NIH was defined as the presence of headache due to nitrate treatment (isosorbide mononitrate 40 mg) after excluding confounding factors. Coronary artery lesion complexity was assessed by the SYNTAX score (SXscore) using a dedicated computer software system. Results: The mean SXscore was lower in the patients with NIH than in patients without NIH (7.3 ± 5.2 vs. 14.4 ± 8.5, respectively; p < 0.001). Additionally, patients with NIH had a lower rate of multivessel disease compared with those without NIH (the mean number of diseased vessels was 1.5 ± 0.7 and 2.0 ± 07, respectively; p < 0.001). In multivariate analysis, increasing age (p = 0.02) and headache (p = 0.001) were found to be independent determinants of SXscore. Conclusion: The present study demonstrated an independent inverse association between NIH and SXscore. The NIH could provide important predictive information about coronary artery lesion complexity in patients with stable CAD.

Relation of presystolic wave on doppler examination to syntax score in patients with acute myocardial infarction

BackgroundThere are few reports demonstrating a relationship between presystolic wave (PSW) and left ventricular function. The aim of the present study was to investigate the associations between PSW and angiographic and echocardiographic characteristics of patients with acute myocardial infarction (AMI).MethodsWe studied 348 consecutive patients with AMI. Pulsed Doppler-echocardiography was used to assess the both diastolic functions and presence of PSW from left ventricular outflow tract. Patients were divided into two groups by the presence or absence of PSW. The Syntax score (SXscore) was calculated from baseline angiograms to assess the complexity and severity of coronary artery disease.ResultsThe overall prevalence of PSW was 51.1%. Compared to patients without PSW, patients with PSW presence had greater left ventricular ejection fraction (LVEF), greater septal a′ velocity, lower mitral E and septal e′ velocity and lower E/A and e′/a′ ratios. Also, median SXscore were significantly lower in the PSW presence group compared to PSW absence group [1 (6–14) vs. 12 (7–18), P = 0.013]. In addition, the number of patients with high-SXscore (> 16) was significantly lower in PSW presence group (24 vs. 42), (P = 0.006). In multiple logistic regression analysis, absence of PSW found independent predictor of high-SXscore (OR 2.297 95% CI 1.235–4.272; P = 0.009).ConclusionsWe found that the presence of PSW was related with higher LVEF, lower SXscore and lower stage diastolic dysfunction in patients with AMI. PSW may be used in prediction of the coronary artery disease complexity and it could help risk stratification in patients with AMI.

Novel treatment of coronary artery fistulae concealing severe coronary artery lesion： using thrombus aspiration catheter as a delivery guide

In this case report, we present the occlusion of multiple coronary artery fistulae originating from proximal left anterior descending (LAD) and right sinus valsavla and empting to the pulmonary artery at the same place. We occluded LAD fistulae by using thrombus aspiration catheter as a delivery guide. To the best of our knowlege, this is the first case of occlusion of coronary fistulae with the help of thrombus aspiration catheter. Our experience may suggest that thrombus aspiration catheters can be used in treating coronary artery fistulae with difficult anotomy.