Predrag Djuric

The Additive Diagnostic Role of Coronary Flow Reserve in Noninvasive Evaluation of Coronary Stenosis on Left Descending Artery Previously Detected by Multislice Computed Tomography

Purpose: Multislice computed coronary angiography (MSCT) provides valuable morphological information about coronary artery disease, but precise quantification of coronary stenosis remains difficult. Transthoracic color Doppler echocardiography (TDE) gives a new insight into the functional significance of coronary luminal narrowing. We have tried to assess the additive value of coronary flow reserve (CFR) determined by TDE over MSCT in prediction of a significant stenosis on the left anterior descending artery (LAD) using the invasive coronary angiography (ICA) as a reference method. Methods: This prospective study included 63 patients in stable cardiac status with previously detected atherosclerotic lesions on LAD by MSCT. CFR assessment by TDE with adenosine infusion was obtained to all patients (feasibility was 96.92%). CFR was determined as ratio between the peak diastolic flow velocity during adenosine infusion and at basal condition, a cutoff value indicating significant stenosis was <2. ICA was preformed to all patients 24–48 hours after CFR. Results: MSCT had sensitivity of 86.36%, specificity 53.66%, positive predictive value 50.00%, negative predictive value 88.00%, and diagnostic accuracy of 65.07% in detection of significant LAD stenosis. CFR had sensitivity 81.81%, specificity 97.06%, positive predictive value 94.74%, negative predictive value 89.19%, and diagnostic accuracy of 91.07%. When the results of both methods were agreed diagnostic accuracy was improved to 92.72%. Conclusion: Additional assessment of CFR by TDE increase diagnostic accuracy of MSCT angiography in detection of significant coronary artery lesions.

Retroperitoneal fibrosis and constrictive pericarditis-IgG4 related diseases: A case report

Retroperitoneal fibrosis (RPF) is a rare disease characterized by infiltration of inflammatory cells and deposition of thickened fibrous tissues. The present study presents the case of a 53-year-old patient treated for generalized weakness and fatigue for 1 year prior to hospitalization. A cardiac ultrasound revealed pericardial effusion that required pericardiocentesis, during which 1,400 ml serous fluid with the characteristics of an exudate was aspirated. A pericardiectomy was performed due to persistent effusion and histological examination indicated pericardial fibrosis. A thoracic-abdominal computed tomography scan revealed the presence of retroperitoneal fibrosis. The patient was treated with corticosteroids and azathioprine. Follow-up examinations showed a significant reduction in the amount of abdominal fibrous tissue and no increase in pericardial effusion 1 year following the end of treatment. The patient continues to have regular follow-up control examinations with a cardiologist and nephrologist.

Unusual occurrence of ventricular tachycardia induced by single bee sting.

Sir, A 35-year-old female patient was admitted to our emergency room with palpitations, 1 h after a single bee sting in the left hand. She was previously in good health, not on any medications and did not have any past allergic reactions. Local inspection of the left hand revealed only mild erythema and swelling. Hemoglobin, thyroid-stimulating hormone, and serum electrolyte levels were within the normal range. Initial 12-lead electrocardiogram (ECG) showed short runs of the nonsustained ventricular tachycardia (VT) [Figure 1]. Only a few seconds later, she suddenly complained of chest discomfort, dizziness, and intensive palpitations. Repeat ECG showed wide QRS-complex tachycardia at a rate of 160 b.p.m. without detectable P-waves [Figure 2]. A bolus of 150 mg amiodarone i.v. was administered, which rapidly terminated VT and restored normal sinus rhythm [Figure 3]. The treatment was continued with bisoprolol 2.5 mg twice daily. Figure 1 Electrocardiogram showing standard Leads I, II, and III: Frequent ectopic ventricular beats with short runs of the nonsustained ventricular tachycardia Figure 2 Electrocardiogram showing standard Leads I, II, and III: Sustained ventricular tachycardia with the right bundle branch block pattern Figure 3 Electrocardiogram showing standard Leads I, II, and III: Regular sinus rhythm just after conversion with amiodarone Transthoracic echocardiography revealed only a mild mitral valve prolapse with mild mitral regurgitation. The patient refused to undergo further invasive investigations (namely coronary angiography and electrophysiological study) so we performed computed tomography-coronary angiography, which showed the normal anatomy of the coronary arteries and the absence of stenosis. The patient was discharged after 48 h and remained asymptomatic during the next 6 months follow-up. A 24-h-holter-ECG was performed after 1–6 months and was normal. Bee stings have been associated with a wide variety of local and systemic reactions including rarely, tachyarrhythmias, commonly occurring in individuals with preexisting heart disease such as left atrial enlargement and left ventricular failure.[1] Although the arrhythmogenic mechanism of the bee venom is still unknown, many pharmacologically active constituents of the bee venom have been isolated including histamine, serotonin, dopamine and noradrenaline, melittin, hyaluronidase, apamin, and phospholipase A2 which may induce tachyarrhythmias in the absence of anaphylaxis.[2] However, in the presence of anaphylaxis tachyarrhythmias are more common, and possible mechanisms include a direct antigen-antibody myocardial reaction, a pharmacological effect of mediators released during anaphylaxis, the effects of agents such as adrenaline used for treatment, hypoxia, hypotension, preexisting heart disease or a combination of several factors.[3] In this patient only mild mitral valve prolapse was demonstrated by transthoracic echocardiography; and to the best of our knowledge, this is the first reported case of VT in a patient with mild mitral valve prolapse-induced by single bee sting in the absence of anaphylaxis. Bee venom as a metabolic insult and resultant autonomic overactivity probably induced tachyarrhythmia in this case. Cardiac magnetic resonance imaging to look for myocardial scarring and electrophysiologic study to look for inducibility of idiopathic outflow tract VT would be indicated in the setting of purely monomorphic VT. Finally, this case implies the necessity of meticulous ECG monitoring in patients presenting with palpitations and ventricular ectopic beats after bee sting, because malignant tachyarrhythmias may occur even in the absence of anaphylaxis in the setting of only mild structural heart abnormalities, as reported here. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.