Nedim Soydan

Reduced capacity of heart rate regulation in response to mild hypoglycemia induced by glibenclamide and physical exercise in type 2 diabetes

OBJECTIVE Decreased heart rate variability (HRV) is associated with enhanced mortality due to abnormal cardiac rhythm. While hypoglycemic events are increasingly common in the treatment of type 2 diabetes, HRV is part of the counter-regulation against low blood glucose levels. We hypothesized that HRV was impaired in mild hypoglycemia in diabetic individuals. MATERIALS/METHODS Hyperinsulinemic-hypoglycemic clamps were performed in twelve type 2 diabetic patients without cardiovascular disease and in non-diabetic subjects matched for age, sex, and weight. In an additional study, hypoglycemic events, induced by either a single morning dose of glibenclamide or physical exercise, were recorded for the subsequent 24h. Blood glucose concentrations and electrocardiograms were continuously monitored. Serum hormone levels, hypoglycemic symptoms, and forearm blood flow were measured at defined time points. RESULTS Occurrence of a symptomatic hypoglycemic episode (mean blood glucose 3.1±0.4 mmol/l) attenuated most of the time and frequency domain measurements in both healthy and diabetic individuals. The magnitude of reduction of HRV parameters was significantly lower in diabetic compared to healthy subjects. Glibenclamide taken in the morning enhanced the daily number of mild hypoglycemic events compared with placebo or moderate exercise. Concordantly, 24-h mean HRV measurements were decreased. CONCLUSION HRV response to hypoglycemia is impaired in type 2 diabetic subjects resulting in a higher than expected risk for sudden arrhythmia following mild hypoglycemic episodes.

Randomized Comparison of Multipolar, Duty-Cycled, Bipolar-Unipolar Radiofrequency Versus Conventional Catheter Ablation for Treatment of Common Atrial Flutter

Comparison of Radiofrequency Versus Conventional Catheter Ablation. Introduction: Radiofrequency (RF) catheter ablation has been established as an effective and curative treatment for atrial flutter (AFL). Approved methods include a drag‐and‐drop method, as well as a point‐by‐point ablation technique. The aim of this study was to compare the acute efficacy and procedural efficiency of a multipolar linear ablation catheter with simultaneous energy delivery to multiple catheter electrodes against conventional RF for treatment of AFL.

Diagnosis of Mixed Plasmodium malariae and P. vivax Infection in a Development Aid Volunteer by Examination of Bone-Marrow Specimens by Real-Time PCR

ABSTRACT Mixed Plasmodium malariae and P. vivax infections in humans are reported very infrequently. The case of a 27-year-old male who sustained malaria quartana/tertiana caused by an unbalanced mixed P. malariae-P. vivax infection is reported here. Conventional tests and serology for malarial parasites were uniformly negative. Identification and quantification of the parasites were accomplished by examining bone-marrow specimens using specific real-time TaqMan PCR.

Quadripolar Left Ventricular Lead in a Patient with CRT-D Does Not Overcome Phrenic Nerve Stimulation

Effective cardiac resynchronization therapy (CRT) requires an accurate atrio-biventricular pacing system. The innovative Quartet lead is a quadripolar, over-the-wire left ventricular lead with four electrodes and has recently been designed to provide more options and greater control in pacing vector selection. A lead with multiple pacing electrodes is a potential alternative to physical adjustment of the lead and may help to overcome high thresholds and phrenic nerve stimulation (PNS).

Left Atrial Appendage (LAA) Closure-Device Disengagement as a Serious Complication and How it Can Be Easily Removed

A stroke attack in the brainstem area as a serious complication of atrial fibrillation (AF) in a 51 year old woman with known paroxysmal AF (CHADS(2) score 3) was treated with LAA occlusion procedure after the complication of arterial bleeding secondary to anticoagulation therapy. LAA closure device embolisation was developed following the LAA occlusion procedure. The device was located and removed successfully from the systemic circulation.

RF ablation of WPW syndrome using Ensite Array balloon mapping and Hansen-Sensei robotic Cool-path catheter

Wolff-Parkinson-White syndromes (WPW) are examples of preexcitation that affects approximately 0.15-0.2% of the general population (2). Of these individuals, 60-70% has no other heart disease, men are affected more often and typically, those affected are young, or healthy individuals. Death from WPW is secondary to the associated arrhythmias or mistreatment of them. RF ablation remains the first line therapy in symptomatic WPW patients. A 22-year-old woman with known preexcitation, WPW was diagnosed at age of 11, had developed 4 episodes of sustained symptomatic palpitations with a pulse up to 190 beats/min., in the past 4 weeks. WPW had been diagnosed in grandfather and aunt. An echocardiography performed in the patient did not demonstrate any abnormalities. The patient’s WPW has been asymptomatic until 4 weeks prior to presentation. Due to the clinical manifestations, an electrophysiological study (EPS) was performed aiming to map and ablate the accessory pathway (3). Catheters were placed to right atrium, ventricle and coronary sinus (CS). During the programmed atrial stimulation, an antegrade transmitting right sided posterior septal pathway was found. Following multiple radiofrequency (RF) ablations, the pre-excitation signal was remained. The EPS was ended, in order to plan a new RF-ablation with the Ensite Array (SJM, St. Paul, MN, USA) (EA) balloon mapping (3). EA provides a virtual activation of intracardiac transmission on a beatto -beat basis (3). At the second EPS, a catheter was placed in the CS, a non-contactmapping EA balloon at the right atrium and the ablation catheter by means also superior and inferior vena cava, and right atrium is mapped. The EA balloon mapped capture beat documented an accessory pathway at the right side of the posterior septum (3). A CS imaging was also performed in order to assess an aneurysm, with a negative result. RF-ablation was performed using remote navigation system, coolpath radiofrequency (Hansen-Sensei, Mountain View, CA, USA) (RNS) (4). The RNS improves the catheter stability and increase procedural success and the safety by avoiding serious complications (4). Focal RF-ablation of the accessory path through RNS was performed, with a total time of 606sec and 8983Ws energy. The ablation of the pathway was successful. In this manner, although the high cost, we have decided to use both EA and RNS considering the young age, and the cardiac anatomy of the patient. In some cases, even though in WPW ablations, the EA and/or RNS usage could be considered in order to increase the success rate and minimize the potential complications of an ablation.

Home monitoring after ambulatory implanted primary cardiac implantable electronic devices: The home ambulance pilot study.

The Home Monitoring (HM) system of cardiac implantable electronic devices (CIEDs) permits early detection of arrhythmias or device system failures. The aim of this pilot study was to examine how the safety and efficacy of the HM system in patients after ambulatory implanted primary CIEDs compare to patients with a standard procedure and hospitalization.

Failure of Femoral Access to Electrophysiological Evaluation Due to Aplasia of the Inferior Vena Cava

We report an interesting case of a man with a persistent left superior vena cava (PLSVC) with left azygos vein who underwent electrophysiological evaluation. Further evaluation revealed congenital dilated azygos vein, while a segment connecting the inferior vena cava (IVC) to the hepatic vein and right atrium was missing. The azygos vein drained into the superior vena cava, and the hepatic veins drained directly into the right atrium. The patient did not have congenital anomalies of the remaining thoracoabdominal vasculature.