Ilknur Can

Assessment of Atrial Conduction in Patients with Scleroderma by Tissue Doppler Echocardiography and P Wave Dispersion

Background: Atrial conduction abnormalities in patients with scleroderma have not been evaluated in terms of P wave duration, P wave dispersion (Pd) and electromechanical coupling measured by tissue Doppler echocardiography. Methods: Twenty-four patients with scleroderma and 24 control subjects underwent resting electrocardiogram (ECG), M mode and tissue Doppler echocardiography. The P wave duration was calculated in all leads of the surface ECG. The difference between the maximum (Pmax) and minimum P wave duration was calculated and defined as Pd. Interatrial and intraatrial electromechanical delays were measured with tissue Doppler tissue echocardiography. Results: The left ventricular dimensions, fractional shortening, and left atrial diameter did not differ between the patients and the controls. Pd and Pmax were significantly higher in patients with scleroderma compared with controls: 51 ± 17 versus 28 ± 7 ms (p < 0.01) and 109 ± 10 versus 93 ± 6 ms (p < 0.01), respectively. There was a delay between the onset of the P wave on surface ECG and the onset of the late diastolic wave (A wave; PA) obtained by tissue Doppler echocardiography in patients with scleroderma compared with controls measured at lateral septal annulus (lateral PA; 122 ± 8 vs. 105 ± 7 ms, p = 0.001), septal mitral annulus (104 ± 11 vs. 93 ± 10 ms, p = 0.01) and tricuspid annulus (right ventricular PA; 71 ± 9 vs. 64 ± 7 ms, p = 0.05). Interatrial conduction time (lateral PA – right ventricular PA) was delayed in patients with scleroderma compared with controls (88 ± 13 vs. 76 ± 11 ms, p = 0.01). A positive correlation was detected between interatrial electromechanical delay (lateral PA – right ventricular PA) and Pd (r = 0.5, p = 0.03). Conclusion: Atrial conduction abnormalities as estimated with Pd and Pmax are significantly higher in patients with scleroderma compared with controls. There is a delay in both intraatrial and interatrial electromechanical coupling intervals in patients with scleroderma.

Initial Evaluation of "Syncope and Collapse". The Need for a Risk Stratification Consensus

Patients presenting with transient loss of consciousness (TLOC) in whom clinical findings suggest a diagnosis of “syncope” account for approximately 1% of emergency department (ED) and urgent care clinic visits ([1,2][1]). On average, 30% to 40% of these patients are admitted to hospital ([3,4][

Association of pulmonary artery obstruction index with elevated heart-type fatty acid binding protein and short-term mortality in patients with pulmonary embolism at intermediate risk

PURPOSE Heart-type fatty acid binding protein (H-FABP) is a sensitive marker of myocardial injury and predictor of worse prognosis in patients with pulmonary embolism (PE). Assessment of right ventricular dysfunction and pulmonary artery obstruction index (PAOI) with computed tomography (CT) has been reported as a predictor of mortality in PE. Therefore, we aimed to assess the correlation between H-FABP and CT angiographic PAOI in PE patients at intermediate risk. MATERIALS AND METHODS Sixty-one patients (28 males; mean age, 62 ± 17 years) with diagnosis of PE were included in this study. CT was performed in all patients, and the following parameters were evaluated: right ventricle/left ventricle ratio (RV/LV), pulmonary artery axial diameter, superior vena cava axial diameter, and PAOI determined with Qanadli score. Blood samples were assessed for H-FABP and troponin levels. Patients were followed for 30 days after discharge. RESULTS Mean PAOI was 57 ± 18%. Eleven patients died during the follow-up period due to PE (18% mortality rate). H-FABP was positive in 21 patients (35%). There was no difference in CT parameters between patients with positive H-FABP and negative H-FABP. In addition, CT parameters were similar between patients who survived and those who did not. RV/LV ratio correlated with PAOI score. Among the biomarkers, troponin levels correlated with both RV/LV ratio and PAOI. H-FABP was an independent predictor of mortality. PAOI and RV/LV ratio did not predict 30-day mortality. CONCLUSION Although H-FABP positivity confers a bad prognosis on PE patients at intermediate risk, PAOI did not predict mortality in this group.

Gerbode-Type Defect Induced by Catheter Ablation of the Atrioventricular Node

A 72-year-old man with a history of dilated cardiomyopathy, prosthetic aortic valve, biventricular intracardiac pacemaker, and permanent atrial fibrillation presented with uncontrolled ventricular response from atrial fibrillation despite pharmacological therapy. He underwent radiofrequency (RF) catheter ablation of the atrioventricular (AV) node to achieve optimal biventricular pacing. AV node ablation was performed via the right femoral vein with a 4-mm tip ablation catheter (EPT, Boston-Scientific) positioned at the AV node just proximal to the His bundle region. RF energy was applied at this site for 60 seconds (55°C) resulting in complete heart block with an escape rhythm of 32 bpm. The next day he was discharged uneventfully. An echocardiogram at 5 months follow-up showed a left ventricular to right atrial (LV-RA) shunt across the membranous septum immediately above the tricuspid valve (online-only Data Supplement Movies I and II and Figure 1A and 1B). This LV-RA shunt (Gerbode-type defect) had a 76-mm Hg gradient across the defect (Figure 1C). Left ventricular ejection fraction was depressed (25% to 30%) and the right ventricle was mildly to moderately dilated. The mechanical aortic prosthetic valve functioned normally with a mean gradient of 17 mm Hg. Review of …

Atorvastatin given prior to electrical cardioversion does not affect the recurrence of atrial fibrillation in patients with persistent atrial fibrillation who are on antiarrhythmic therapy.

Objective: In this study, our aim was to evaluate the effect of a higher dose of atorvastatin on the recurrence rate of atrial fibrillation (AF) after electrical cardioversion (EC) in addition to antiarrhythmic therapy. Subjects and Methods: 48 patients with persistent AF were included in this study. The patients were randomized to an atorvastatin 40-mg treatment group and a control group. Atorvastatin was started 3 weeks before EC and was continued for 2 months after EC. EC was performed using biphasic shocks after 3 weeks of treatment with the orally administered anticoagulant warfarin. Lipid and inflammatory parameters (high-sensitivity C-reactive protein, white blood cell count and fibrinogen level) were evaluated at the baseline and before EC. The endpoint of this study was electrocardiographically confirmed recurrence of AF of >10 min. Results: There were no significant differences in baseline characteristics and lipid and inflammatory marker levels between the treatment and control groups. Total cholesterol and low-density lipoprotein levels were significantly decreased in patients taking atorvastatin for 2 months compared with baseline values (174 ± 31 vs. 129 ± 25 mg/dl, p = 0.001, and 112 ± 23 vs. 62 ± 20 mg/dl, p = 0.001, respectively), while no significant change occurred in control patients (168 ± 26 vs. 182 ± 29 mg/dl, p = 0.07, and 99 ± 18 vs. 108 ± 26 mg/dl, p = 0.1, respectively). At the end of the 2-month follow-up period, 9 patients (20.5%) experienced AF recurrence, and there was no significant difference in AF recurrence rate between the treatment and control groups (26 vs. 13%; p = 0.2). Conclusion: Atorvastatin therapy prior to EC does not prevent the recurrence of arrhythmia in patients with persistent AF who are receiving antiarrhythmic therapy.

Case report: an unusual heart rhythm associated with organophosphate poisoning.

Organophosphate pesticides have emerged as a common cause of poisoning, particularly in developing countries. The most common electrocardiographic abnormalities observed in organophosphate poisoning are sinus tachycardia, QT interval prolongation, and, very rarely, ventricular arrhythmias. We report a case of organophosphate poisoning associated with atrial fibrillation, right bundle branch block, QT interval prolongation, and intermittent narrow QRS complexes that were most likely due to automaticity from the region of the left posterior fascicle.

The effect of VVI pacing on P-wave dispersion in patients with dual-chamber pacemakers.

The incidence of atrial fibrillation is higher in patients with VVI pacing mode than DDD pacing mode, but the likely mechanism is not clearly understood. We aimed to evaluate whether short-term VVI pacing increases inhomogeneous atrial conduction by using P-wave dispersion. Forty-seven patients (32 men, 15 women, mean age 54 ± 13 years) with DDD pacemakers were enrolled in this study. Twelve-lead surface ECGs were obtained in all patients during VDD pacing after an observation period of 1 week. The mode was then changed to VVI and 12 lead surface ECGs were obtained after another 1-week observation period. P-wave durations were calculated in all 12 leads in both VDD and VVI pacing modes. The difference between the maximum and the minimum P-wave duration was defined as the P-wave dispersion (PWD = Pmax − Pmin). P-wave maximum duration (Pmax) calculated in VVI pacing mode was significantly longer than in VDD pacing mode (128 ± 19 vs 113 ± 16 ms, P < 0.001). There was no significant difference in the P-wave minimum durations (80 ± 13 ms vs 79 ± 12 ms, P = 0.7) between VVI pacing and VDD pacing. The P-wave dispersion value was higher in the VVI pacing mode than in the VDD pacing mode (48 ± 8 ms vs 34 ± 7 ms, P < 0.001). Short-term VVI pacing induces prolongation of Pmax and results in increased P-wave dispersion, which might be responsible for the development of atrial fibrillation more frequently in these patients than in those with the VDD pacing mode.

Displacement of the heart by diaphragm: is this heart alternating?

A-64-year-old man was admitted to the emergency department because of dyspnea. Twelve-lead ECG revealed alternating QRS complexes. In consequence of diagnostic tests, i.e., chest tomography showed eventration of the left diaphragm. In this case, we present an unusual case of electrical alternans due to diaphragmatic eventration.

Is it a typical crosstalk: Need for re-implantation?

With constantly evolving technology and an ever‐increasing number of patients with pacemakers, clinicians will encounter various pacemaker malfunctions in their practice. While some of these issues can be solved even by using only the pacemakers mode settings, others require re‐intervention; neglecting a pacemakers malfunction without full investigation threatens the patients life. In this report, we describe a patient with a dual‐chamber pacemaker with neglected or unresolved dyssynchronization that occurred 2 years after implantation.

Pyridostigmine in the treatment of postural orthostatic tachycardia syndrome

A 34-year-old female patient was admitted with the complaints of inability to stand upright, palpitations, dizziness, and fatigue in the upright posture for the last one year. She was found to stand upright for less than one minute without symptoms. Tilt table testing showed that, compared to baseline her heart rate increased 55 beats/min in the fifth minute of the test with the symptoms of palpitations, fatigue and sweating without any significant change in her blood pressure. Postural orthostatic tachycardia syndrome was diagnosed, and pyridostigmine treatment was started. Four months after treatment her symptoms were relieved so that she was able to function as a nurse.