Konstantinos Chouchoulis

A successfully thrombolysed acute inferior myocardial infarction due to type A aortic dissection with lethal consequences: the importance of early cardiac echocardiography

Thrombolysis, a standard therapy for ST elevation myocardial infarction (STEMI) in non-PCI-capable hospitals, may be catastrophic for patients with aortic dissection leading to further expansion, rupture and uncontrolled bleeding. Stanford type A aortic dissection, rarely may mimic myocardial infarction. We report a case of a patient with an inferior STEMI thrombolysed with tenecteplase and followed by clinical and electrocardiographic evidence of successful reperfusion, which was found later to be a lethal acute aortic dissection. Prognostic implications of early diagnosis applying transthoracic echocardiography (TTE) are described.

Predicting torsade de pointes in acquired long QT syndrome: optimal identification of critical QT interval prolongation.

Objectives: To determine the optimal method of ventricular repolarization assessment in predicting torsade de pointes (Tdp) in acquired long QT syndrome (LQTS) within the context of the recommended cutoff levels of concern for QT/corrected QT (QTc) interval prolongation. Methods: Twenty-nine patients with LQTS and Tdp (age 66 ± 11 years) and matched controls were studied. Standard 12-lead electrocardiograms were utilized to evaluate ventricular repolarization by using six different QT/JT heart rate correction methods. We compared the distribution of QT/QTc and JT/corrected JT intervals of patients who experienced Tdp with (1) the corresponding intervals in the matched controls and (2) the recommended cutoff levels for QT/JT interval prolongation. Results: Patients with Tdp (23 with narrow QRS, 6 with wide QRS) had longer ventricular repolarization intervals than controls (p < 0.001). For patients with narrow QRS, the QTc interval as determined firstly by the method of Hodges (t = 7.56, c = 0.933, p < 0.001), followed by the Nomogram and Fridericia methods, best discriminated Tdp patients from controls and provided the optimal balance between sensitivity and specificity at all three cutoff levels. For patients with wide QRS, the JT interval or, alternatively, the Hodges method seemed most useful. Conclusions: Assessment of ventricular repolarization by the Hodges, Nomogram and Fridericia methods performs best in identifying subsequent Tdp.

Optimal QT/JT interval assessment in patients with complete bundle branch block.

Background: Prolonged ventricular repolarization duration confers increased risk for malignant ventricular arrhythmias. We sought to clarify the optimal method of QT/JT interval assessment in patients with complete bundle branch block (BBB).

Heart echinococcus cyst as an incidental finding: early detection might be life-saving

We present a 46-year-old female smoker who was admitted to the emergency department of our hospital due to cough with blood-tinged sputum for the last four days before admission. Using echocardiography and Multi-Detector Computed Tomography (MDCT) heart Echinococcosis was diagnosed. Echinococcosis is a severe health issue in some geographical regions of the world. Hydatid infection of the heart is rare and the clinical presentation is usually insidious but there is always the lethal hazard of cyst perforation. Early diagnosis and an integrated treatment strategy are crucial. The results of surgical treatment of heart echinococcosis are better than the conservative strategy only. Extraction of the cyst combined with chemotherapy peri or post operative aiming to decrease the recurrences, consists the lege artis method of encountering this medical entity. Surgical excision was performed and the patient had an uneventful recovery and follow up at six and twelve months.

Effect of heart rate on the intrinsic and the ventricular-paced QRS duration

BACKGROUND We evaluated the effect of heart rate on the intrinsic and the ventricular-paced QRS duration in implanted device recipients with normal or reduced left ventricular ejection fraction (EF). METHODS We studied 239 outpatients with preserved intrinsic ventricular activation and normal (n=92) or reduced (n=147) EF who had apical (RVA) or mid-septal (RVS) right ventricular lead position. The QRS duration was measured at baseline and during atrial-based pacing at increased heart rate to ensure intrinsic or ventricular-paced QRS activation. RESULTS The heart rate increase shortened the intrinsic QRS only in patients with normal EF, and further prolonged the ventricular-paced QRS in patients with reduced EF and either narrow or wide QRS (p<0.001), irrespective of RVA or RVS pacing (p<0.01). CONCLUSION Heart rate increase is associated with further QRS prolongation in patients with reduced EF, regardless of RVA or RVS pacing site.

Allergic reaction reveals a non-lethal late stent thrombosis. A new subtype of Kounis syndrome?

Kounis syndrome is defined as the coexistence of acute coronary syndromes (ACS) with situations associated with allergic or hypersensitivity as well as anaphylactic or anaphylactoid insults to a variety of medical conditions, environmental andmedication exposures. Activation of mast cells releasing a variety of cytokines and chemokines and inflammatory mediators such as histamine, neutral proteases, arachidonic acid products and platelet activating factor has been implicated [1,2]. Initially two subtypes had been described: concerning normal or nearly normal vessels (Type I) and severe diseased atheromatic vessels (Type II). Recently a third typeof this syndromehasbeen suggested and is associated with drug-eluded stent (DES) thrombosis [3]. In this case presentation,wedescribe a new “subtype” of this relatively novel, but not infrequent in clinical practice, syndromewhichcombines allergy reaction, ACS and late thrombosis of a DES. A 51-year old male with a history of ischemic heart disease was admitted on December 2010 to our emergency room (ER) with nausea, vertigo and generalized pruritus. His complaints had started after ingesting an oral dose of 500 mg Cefaclor for pharyngitis. On physical examination he had dyspnea with tremor and erythematous rash covering his entire body. He was treated in the ambulance with i.v. 125 mgMethylprednisolone and subsequently in the ERwith i.v. 250 mg Hydrocortisone, 50 mg Ranitidine and i.m. 0.5 ml Adrenaline (1:1000 dilution). His ECG had Q waves at the inferior leads (Fig. 1A) and the troponin-I test was normal (b0.05 ng/ml with reference values: 0.4 ng/

Ischemia-triggered pause-dependent polymorphous ventricular tachycardia storm complicating acute myocardial infarction terminated by complete coronary reperfusion.

A 53-year-old man was referred for coronary angiography following fibrinolytic therapy for acute ST-segment elevation myocardial infarction (AMI) of the inferior wall. The patient had negative personal and family history, and he reported no drug use. Cardiac risk factors included obesity and tobacco abuse. The 12-lead ECG showed a typical course of decreased ST segment elevation with Q waves in the inferior leads, biphasic/inverted T waves in V2–5 and moderate QT interval prolongation. Angioplasty of a significant stenosis of the culprit right coronary artery (RCA) was performed by 2-vessel disease with a remaining isolated critical stenosis of the left anterior descending coronary artery (LAD). The patient returned to the coronary care unit asymptomatic, but soon after falling asleep, along with apnea episodes, recurrent pause-dependent polymorphous ventricular tachycardia (PVT) attacks were noted (Fig. 1). Emergent repeat angiography demonstrated no worrisome appearance of the stented RCA and enabled to proceed with angioplasty of the LAD stenosis. Following the second angioplasty procedure, no further nocturnal or daytime PVTs or pauses were seen. A distinct type of PVT-torsade de pointes during the subacute phase of uncomplicated myocardial infarction is associated with deep inverted T waves and excessive QT interval prolongation in the absence of ongoing ischemia. Our patient presented dramatic clustering of PVT episodes, paradoxically, after successful angioplasty of the culprit infarctrelated artery. Early afterdepolarizations in Purkinje fibers

PREDICTORS OF HIGH ON-TREATMENT PLATELET REACTIVITY EARLY AFTER CLOPIDOGREL LOADING IN ST ELEVATION MYOCARDIAL INFARCTION PATIENTS

BACKGROUND Given that platelet inhibition is crucial when ST-elevation myocardial infarction (STEMI) patients undergo primary PCI (PPCI), the identification of factors associated with early high on-treatment platelet reactivity may be important. METHODS AND RESULTS Consecutive STEMI patients admitted for PPCI were considered for platelet reactivity assessment 2 h after loading with 600 mg clopidogrel using the VerifyNow point-of-care P2Y12 assay. A cut-off of ≥235 P2Y12 reaction units indicated high on-treatment platelet reactivity. Out of 92 STEMI patients, 63 (68.5%) were found to have high on-treatment platelet reactivity. Patients with high on-treatment platelet reactivity had received upstream clopidogrel loading and pantoprazol more frequently, had lower admission hemoglobin and tended to have an impaired renal function compared to those with an adequate response to clopidogrel. On multivariate analysis, upstream clopidogrel loading and creatinine clearance <60 ml/min were independently associated with higher risk for high on-treatment platelet reactivity (relative risk [RR]=1.55, 95% confidence interval [CI]: 1.11-2.17, P=0.01; RR=1.31, 95% CI: 1.008-1.71, P=0.04, respectively). CONCLUSIONS In patients with STEMI undergoing PPCI, use of upstream clopidogrel and impaired renal function independently predict high on-treatment platelet reactivity assessed as early as 2h following 600 mg of clopidogrel loading dose on point-of-care P2Y12 function assay.