Kazim Baser

Evaluation of left ventricular diastolic functions in patients with frequent premature ventricular contractions from right ventricular outflow tract.

This study was sought to examine the effects of repetitive monomorphic premature ventricular contractions (PVCs) on left ventricular (LV) diastolic function. Thirty-three symptomatic patients (Study group, 10 males, mean age 40 ± 8 years) with normal LV systolic function and repetitive PVCs originating from the right ventricular outflow tract (RVOT-PVCs) on 24-h Holter monitoring, and 30 healthy controls (Control group, 9 males, mean age 37 ± 9 years) were enrolled in the study. None of the patients had structural heart disease. Diastolic function was assessed by echocardiographic mitral inflow pattern and tissue Doppler imaging. The study group displayed a lower E/A ratio, longer isovolumetric relaxation time (IVRT), and longer E-wave deceleration time (EDT). In the study group 13 patients showed impaired relaxation. While mean values of the systolic velocity (Sa), early diastolic velocity (Ea), and early/late diastolic velocity (Ea/Aa) ratio were significantly lower in the study group, the Aa velocity and E/Ea ratio were significantly higher. Ea velocity was <10 cm/s in 7 study patients. Mitral inflow pattern and Ea velocity was normal in all controls. Significant correlations were found between ventricular premature beats percentage and early to late transmitral flow velocity ratio, EDT, IVRT, Ea velocity, the Ea/Aa ratio, and the E/Ea ratio. In multivariate analysis, total PVC count and age were found to be independent predictors of impaired relaxation. These results suggest that repetitive monomorphic RVOT-PVCs lead to abnormalities of LV diastolic function that may contribute to clinical symptoms in patients with structurally normal hearts.

Perception paradox between the doctors and patients in the industrial-bureaucratic age of medicine: Defensive versus offensive medicine in anticoagulation and atrial fibrillation ablation

Dear Editor, We read with great interest the article by Badin et al.1 We want to address some points that merit more attention. Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke, but undertreatment and undereducation of AF patients continue2 despite their high risk of stroke and clear indication for anticoagulation according to established risk scores.3,4 Many individuals diagnosed with AF lack awareness about their diagnosis, coupled with a limited understanding of both the risks and benefits of AF treatment.5,6 Physician and patient beliefs regarding the risk associated with AF and clinical events differed. Whereas the most feared complication of the AF by the patient is the ischemic stroke, the bleeding complication is the most feared complication by thephysicians.7 Recently, several studieshave focusedon theeffects of “defensive medicine” on physicians and patients,7,8 and the main issue that the physicians’ physiological and medicolegal fear is the risk of intracranial hemorrhage in association with anticoagulants. It is critical that physicians talk to their patients and/or their families about the importance of the anticoagulation therapy and of continued adherence to the therapy. Indeed, it has been shown that the well-educated patients are willing to accept amuch higher risk of bleeding if we could prevent strokes.9 However, it has been reported that more than one in four physicians felt that AF was either too complicated to explain to patients or that they did not have enough time to fully explain AF in their consultations with patients.10 There is also another paradox between the perception of AF ablation and its clinical purpose in both doctors and patients. Catheter ablation/isolationof pulmonary triggershasbeenabreakthrough innovation in thefieldofAF.However,AFguidelines recommend that symptom relief should be the primary goal in AF ablation and it should be preferred in “highly selected” and thoroughly educated patients. Therefore, the patients’ perceptions of their symptoms and concerns about the necessity of ablation procedures at diagnosis should be specifically addressed as part of their medical management.11 However, it is unclear whether patients and physicians understand that AF ablation has been shown to only improve symptomology and not reduce morbidity or mortality.1,12 All patients should be told there is no randomized controlled trial showing the AF ablation lowers the stroke risk or death; however, there is a tendency to overestimate the value and underestimate the risk of the intervention for many proceduralists in medicine and surgery. A counterpart to

Right ventricular outflow tract function in chronic heart failure

Background Heart failure (HF) is a common, progressive, complex clinical syndrome and a subset of HF patients has symptoms out of proportion to the resting hemodynamics and left ventricular ejection fraction (LVEF). Right ventricular (RV) function is a powerful prognostic factor in HF, but assessing it is a challenge because of the right ventricles complex geometry. Objective The aim of this study was to investigate the clinical application value of RV outflow tract (RVOT) function measured by transthoracic echocardiography in HF patients. Method We prospectively investigated 36 chronic HF patients with dilated heart and LV systolic dysfunction and 21 healthy control subjects (normal ventricular function and ECG, and no cardiac risk factors). In addition to clinical and conventional echocardiographic parameters, RVOT size and fractional shortening (RVOT-FS) parameters were analyzed. Results The RVOT-FS was less in HF patients than healthy controls (18.8 ± 15.7 vs 55.8 ± 6.7, p < 0.001) and correlated positively with TAPSE (r = 0.814, p < 0.001) and inversely with SPAP (r = −0.728, p < 0.001) and functional capacity (r = −0.842, p < 0.001). There was a statistically significant difference in RVOT-FS among the HF subgroups with regard to NYHA functional capacity (p < 0.001), although there was no statistically significant difference with regard to LVEF. Conclusion Although the apparent discordance between LVEF and the degree of functional impairment in HF is not well understood, it may be explained in part by alterations in RV function. We found that the RVOT-FS was a noninvasive and easily applicable measure of RV function and might be used for a comprehensive evaluation and follow-up of HF patients with a combined assessment of RV by other RV parameters.

Arrhythmogenic Noncompaction Cardiomyopathy: Is There an Echocardiographic Phenotypic Overlap of Two Distinct Cardiomyopathies?

The clinical diagnosis of right ventricular (RV) cardiomyopathies is often challenging. It is difficult to differentiate the isolated left ventricular (LV) noncompaction cardiomyopathy (NC) from biventricular NC or from coexisting arrhythmogenic ventricular cardiomyopathy (AC). There are currently few established morphologic criteria for the diagnosis other than RV dilation and presence of excessive regional trabeculation. The gross and microscopic changes suggest pathological similarities between, or coexistence of, RV-NC and AC. Therefore, the term arrhythmogenic right ventricular cardiomyopathy is somewhat misleading as isolated LV or biventricular involvement may be present and thus a broader term such as AC should be preferred. We describe an unusual case of AC associated with a NC in a 27-year-old man who had a history of permanent pacemaker 7 years ago due to second-degree atrioventricular block.

PP-333: BUNDLE BRANCH REENTRANT VENTRICULAR TACHYCARDIA IN A PATIENT WITH NO STRUCTURAL HEART DISEASE

PP-332 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR POCKET INFECTION CAUSED BY KLEBSIELLA PNEUMONIAE F. Ertas, H. Acet, O. Deveci, E. Yula, R. Tekin, Z. Ariturk, M.A. Elbey, Y. Islamoglu, M.S. Ulgen, S. Soydinc. Department of Cardiology, Kiziltepe State Hospital, Mardin, Turkey; Department of Cardiology, Diyarbakir Training and Research Hospital, Diyarbakir, Turkey; Department of Infectious Diseases, Kiziltepe State Hospital, Mardin, Turkey; Department of Microbiology, Kiziltepe State Hospital, Mardin, Turkey; Department of Infectious Diseases and Clinical Microbiology, Diyarbakir Children’s Hospital, Diyarbakir, Turkey; Department of Cardiology, Dicle University Faculty of Medicine, Diyarbakir, Turkey