Necmi Ata

Noncompaction of the Ventricular Myocardium: Report of Two Cases With Bicuspid Aortic Valve Demonstrating Poor Prognosis and With Prominent Right Ventricular Involvement

Noncompaction of the ventricular myocardium is a rare, unclassified cardiomyopathy due to an arrest of myocardial morphogenesis. The characteristic echocardiographic findings consist of multiple, prominent myocardial trabeculations and deep intertrabecular spaces communicating with the left ventricular (LV) cavity. The disease typically involves the LV myocardium, but right ventricular (RV) involvement is not uncommon. The clinical manifestations include heart failure (HF) signs, ventricular arrhythmias and cardioembolic events. Noncompacted myocardium may occur as an isolated cardiac lesion, as well as it can be in association with congenital anomalies. We describe two illustrative cases of noncompaction of the ventricular myocardium, a 19‐year‐old male with bicuspid aortic valve and progressive worsening of HF, and a 61‐year‐old male with marked RV involvement in addition to LV apical involvement, both with the typical clinical and echocardiographic features of the disease. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Cigarette Smoking Increases Plasma Concentrations of Vascular Cell Adhesion Molecule-1 in Patients with Coronary Artery Disease

Cigarette smoking adversely affects endothelial function and increases risk of coronary artery disease (CAD). The pathogenesis of coronary atherosclerosis is currently thought to involve interactions between inflammatory cells and vascular endothelium. Adhesion molecules play a pivotal role in the accumulation of inflammatory cells at the endothelium. Little is known about the role of cigarette smoking in this atherosclerotic inflammatory process. The aim of this study was to evaluate the effects of cigarette smoking on the plasma concentrations of soluble vascular cell adhesion molecule-1 (VCAM-1) in patients with CAD. The soluble VCAM-1 level was quantified in smoking CAD patients (n=19) in comparison to those from patients with CAD alone (n=10). Plasma concentrations of soluble VCAM-1 were measured by enzyme-linked immunosorbent assay. The soluble VCAM-1 level was found significantly higher in smokers than in nonsmokers (32.1279 ±21.6421 vs 9.4570 ±7.8138 ng/mL, p<0.01), and in patients with previous myocardial infarction (MI) than in those without previous MI, but not significant statistically (27.7279 ±22.8813 vs 17.8170 ±15.9172 ng/mL, p>0.05). No significant difference was observed for soluble VCAM-1 levels between hypertensive and nonhypertensive patients, multivessel and one-vessel disease, or anterior and inferior MI localizations. The present study suggests that in patients with CAD, smoking leads to elevated levels of soluble VCAM-1 that may clarify one of the mechanisms of its accelerating effect on the atherosclerotic process.

Levosimendan is not effective in reducing pulmonary pressures in patients with idiopathic pulmonary arterial hypertension: report of two cases.

Currently, prostacyclin, endothelin receptor antagonists and phosphodiesterase inhibitors are recommended therapy in idiopathic pulmonary arterial hypertension. However, each of these drugs has limited efficacy in the improvement of clinical symptoms, pulmonary hemodynamics and long-term survival. Levosimendan, a novel calcium-sensitizing inodilator agent, has been shown to have pulmonary vasodilatory action. However, the potential pulmonary vasodilating effect of levosimendan in patients with idiopathic pulmonary arterial hypertension remains unclear. Levosimendan administered in two patients with nonvasoreactive idiopathic pulmonary arterial hypertension exhibited deterioration in clinical status, and, contrary to what was expected, levosimendan was found to increase pulmonary pressures and did not lead to a substantial improvement of the patients condition.

Initiation of Monomorphic Ventricular Tachycardia: Electrophysiological, Clinical Features, and Drug Therapy in Patients With Implantable Defibrillators

At least 2 distinct patterns of sustained monomorphic ventricular tachycardia (MVT) have been ascribed during analysis of stored intracardiac electrograms retrieved from implantable cardioverter defibrillators and Holter recordings in patients with ventricular arrhythmia. We aimed to investigate the electrophysiological features of MVT with different initiation patterns in patients with implantable cardioverter defibrillators and to assess whether there is a relationship of the initiation patterns of sustained MVT with clinical characteristics and efficacy of antiarrhythmic therapy. Seventy-four stored intracardiac electrograms in 21 patients (mean age of 68.2 +/- 4.2 years) with MVT were evaluated. Cardiovascular diagnosis included coronary artery disease in 85.7% of the patients. All MVT episodes were classified as those initiating with ventricular premature beats (nonsudden onset MVT) and those without ventricular ectopy preceding tachycardia (sudden onset MVT). There was significant difference in left ventricular ejection fraction between MVTs with different initiation pattern, being the lower in those with nonsudden onset (33.6% +/- 38.4% vs. 38.4 +/- 7.0%, P <.04). Ventricular tachycardia cycle length was shorter in group of MVT with nonsudden onset as compared with sudden onset (338.5% +/- 48.1% vs. 376.8% +/- 57.0%, P <.02). Tachycardia with sudden onset was associated with shorter preceding RR interval than tachycardia with nonsudden onset (821.8 +/- 136.2% vs. 748.7 +/- 107.7%, P <.01). There were no significant differences in the type of antiarrhythmic drug therapy used between groups (P >.05). Monomorphic ventricular tachycardias with nonsudden onset occurred more frequently than with sudden onset, without precipitating RR cycles shortening, are faster in rate, associating with lower ejection fraction. Monomorphic ventricular tachycardias with sudden onset are characterized by preceding shortening of RR intervals, slower cycle length, and less worsening of ejection fraction.

Fractal scaling of laser Doppler flowmetry time series in patients with essential hypertension

The full diagnostic potential of the fractal complexity measure, α, of detrended fluctuation analysis (DFA) has not been realized yet. To reveal the impaired mechanisms in the blood flow regulation in patients with essential hypertension (EHT), we studied the laser Doppler flowmetry (LDF) time series by applying DFA. Forearm microvascular blood flow was measured by LDF during supine rest. After a 15 min baseline recording, microvascular response to thermal hyperemia was measured over 30 min. We found three distinct scaling regions; corresponding to the integration of local mechanisms, cardiac effect on local blood flow, and the coupling of extrinsic factors (cardiac and respiratory) to local blood flow by myogenic mechanism. In the control group, local scaling exponent, α(L)=0.96 ± 0.08, did not change but cardiac scaling exponent, α(C)=1.53 ± 0.05, for baseline signal was increased to α(CT)=1.73 ± 0.10 and cardio-respiratory scaling exponent, α(CR)=0.73 ± 0.19, was decreased to α(CRT)=0.24 ± 0.06 during vasodilatation in response to local heating. However, we found significantly different scaling exponents, α(LT)<1, α(CT) ≥ α(C)<1.5 and α(CR) ≈ α(CRT)>0.5 in patients with EHT. Our findings suggest that the local regulatory and the cushioning peripheral vascular functions are impaired in patients with EHT, and vascular/microvascular pathology can be evaluated by applying DFA to LDF signal.

Importance of Initiation Pattern of Polymorphic Ventricular Tachycardia in Patients with Implantable Cardioverter Defibrillators

Background: Stored intracardiac electrograms (ICEGs) are helpful in understanding the initiation mechanisms of sustained ventricular arrhythmias and in determining the appropriateness of the therapy delivered by implantable cardioverter defibrillators (ICDs).

Widespread thrombosis associated with recurrent intracardiac masses in a patient with Behçet's disease.

Behcet’s disease (BD) is a relapsing chronic inflammatory disease of unknown etiology. BD was initially characterized by a triad of recurrent oral aphtous ulcerations, genital ulcerations and uveitis, but it is now more commonly recognized to be a multi-system disease concomitant with vasculitis as its main pathological finding [1]. Although vascularmanifestations, particularly venous thrombosis, arteritis, and aneurysm formations, are not uncommon, a direct cardiac involvement is to be determined only rarely. We herein describe a patient with BD who developed recurrent operated intracardiac thrombi associated with inferior vena cava thrombosis, pulmonary arterial thrombosis, renal vein thrombosis and Budd–Chiari syndrome.

P wave amplitude and duration may predict immediate recurrence of atrial fibrillation after internal cardioversion.

Background: Although internal cardioversion (IC) for atrial fibrillation (AF) is effective at restoring sinus rhythm, immediate recurrence (IR) of AF after IC is a major and largely unpredictable clinical problem. The purpose of the study was to determine the role of P wave duration and amplitude in prediction of IR of AF after IC. Forty‐five consecutive patients undergoing IC for chronic AF were evaluated.

Mode of onset of polymorphic ventricular tachycardia in acute myocardial infarction

BACKGROUND Polymorphic ventricular tachycardia (PVT) can occur during acute myocardial infarction (MI). In the past, studies investigated the initiation pattern of ventricular tachycardias in different patient populations; however, the mode of onset of PVT in acute MI patients has not been investigated previously. OBJECTIVE To retrospectively investigate the electrophysiological features of PVT with different initiation patterns in acute MI patients to assess whether there is a relationship of the initiation patterns of PVT with clinical and electrophysiological characteristics. METHODS Sixty-two rhythm strips defined as PVT from 53 patients (mean [± SD] age 63±8 years) with acute ST elevation MI were analyzed. All patients were monitored while they were hospitalized in the coronary care unit, and the electrocardiogram strips were obtained from continuous monitoring. PVT was defined as sudden-onset tachycardia if it was not preceded by ventricular ectopic beats. PVT that was preceded by single or multiple ectopic beats was defined as nonsudden-onset tachycardia. RESULTS Nonsudden-onset episodes were more common than suddenonset episodes (40 episodes [64.5%] versus 22 episodes [35.5%]). In the nonsudden-onset group, 25 episodes (62.5%) were initiated after a single ectopic beat, while 15 episodes (37.5%) were initiated after multiple complexes. The mean (± SD) left ventricular ejection fraction of patients with nonsudden-onset PVT was decreased (53±6% versus 65±7%, P<0.01). Nonsudden-onset tachycardias had lower coupling intervals than suddenonset tachycardias. Similarly, the PVT cycle length was shorter in the presence of nonsudden-onset initiation. When nonsudden-onset PVT episodes were further subclassified based on the morphology of the first beat of tachycardia, 26 PVTs (65%) had a first beat of tachycardia similar to the subsequent PVT beats and 14 (35%) did not. CONCLUSIONS These results demonstrate that PVT is often preceded by ventricular ectopy in acute MI patients. Nonsudden-onset PVT is usually characterized by a lower coupling interval, shorter PVT cycle length and an associated lower ejection fraction.

Atrial Fibrillation after Percutaneous Coronary Intervention: Predictive Importance of Clinical, Angiographic Features and P-Wave Dispersion

Atrial fibrillation (AF) may occur during or after percutaneous coronary interventions (PCI). The purpose of the study was to determine the clinical, angiographic and electrophysiological predictors of AF after PCI. 225 patients undergoing PCI (mean age of 65 ± 11 years) who had sinus rhythm (SR) before balloon inflation were taken to study. Of these 22 developed AF in catheterization laboratory after balloon inflation or in 24 h following PCI (AF group), 203 did not (SR group). The patients in AF group were older (67 ± 9 vs. 63 ± 8 years, p < 0.05) and their ventricular ejection fraction was lower than SR group (56 ± 5 vs. 45 ± 7%, p < 0.05). The P-wave dispersion was significantly higher in AF group than SR group (53 ± 8 vs. 29 ± 10 ms, p < 0.001). For the patients with ST elevation myocardial infarction, the time from the onset of symptoms to balloon inflation was 3.7 ± 1.7 h in SR group. It was longer in AF group (4.1 ± 1.8 h, p < 0.05). TIMI perfusion grades 2 and 3 were achieved in 23 of 27 patients in SR group, and 5 of 8 patients in AF group. Multivessel disease was documented in 93 of the patients in SR group, and 12 in AF group. Clinical reperfusion was thought to be established in 20 in SR group, and 4 in AF group. In conclusion, our results show the importance of clinical factors, angiographic results and P-wave analysis in prediction of AF following PCI.