Walid Gharzuddine

Ventricular late potentials among thalassemia patients

BACKGROUND Iron induced cardiac abnormalities remain the number one cause of death among thalassemia major (TM) patients. Signal averaged ECG (SAECG) was suggested to predict ventricular tachycardia as the underlying substrate for up to 5% incidence of sudden cardiac death among TM patients. The prevalence of ventricular late potentials (VLP) among different TM populations varied (3-31%); therefore to further clarify this we here describe the incidence of VLP among TM patients over a 7 year follow up period (1997 to 2004). METHODS 26 TM patients were randomly selected from a group of 240 TM patients. SAECG, regular ECG, echocardiography-Doppler were analyzed during the study period. Ferritin levels and cardiac complaints were registered from an interview and chart review. RESULTS Mean QRS duration increased from 89.23 (+/-10.60) ms in 1997 to 94.27 (+/-10.91) in 2004 (p<0.01), mean late amplitude signal (LAS) duration increased from 23.04 (+/-7.68) ms in 1997 to 27.69 (+/-6.82) ms in 2004 (p=0.01), whereas mean root mean square voltage RMS decreased from 80.85 (+/-51.19) mV in 1997 to 45.12 (+/-21.42) mV in 2004 (p<0.01). Changes in QRS duration and RMS voltage were found to be linearly correlated with average of ferritin over years (r=0.38, p=0.03 and r=-0.47, p=0.01 respectively); and only 1 patient developed VLP over 7 years. CONCLUSION The incidence of VLP is 3.8% in the TM population over 7 years, despite the presence of significant changes in all SAECG criteria. RMS voltage and QRS duration changes over time seem to be related to iron overload measured by ferritin level.

Traumatic pseudoaneurysm of the left sinus of Valsalva: a case report.

Deceleration injuries of the aorta result in tears that often lead to exsanguinating hemorrhage. The site is most often at the aortic isthmus, with injuries of the aortic root being rare. A minority of patients survive long enough to reach the hospital where prompt diagnosis and treatment are essential for survival. We hereby report on a patient who had a pseudoaneurysm of the left sinus of Valsalva 13 years after a deceleration accident, presumably caused by a contained rupture of the aortic root. Transesophageal echocardiography was of great value in studying the features of the pseudoaneurysm and its relation to the left main coronary artery and left upper pulmonary vein.

Sequential use of thrombolytic agents for thrombosed mitral valve prosthesis during pregnancy.

Abstract Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis.We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis.When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.

Five-Year Trial of Deferiprone Chelation Therapy in Thalassaemia major Patients

Twelve thalassaemia major patients have been given deferiprone 75 mg/kg body weight daily as iron chelation therapy for 5 years. Their ages ranged from 18 to 34 years (mean 24.2) at the end of the study. Two patients were hepatitis C virus (HCV) mRNA positive and a further 5 were positive for HCV antibody. The mean serum ferritin level fell significantly from 4,302 ± 2,245 µg/l SD at baseline to 3,032 ± 1,155 µg/l at 2 years (p = 0.037) and 2,229 ± 1,070 µg/l (p = 0.007) at 5 years. At the end of the study, liver iron ranged from 3.59 to 23.7 mg/g dry weight (mean 11.9 ± 5.4), 3 patients having levels >15 mg/g. There was no significant change in serum AST levels, but ALT levels fell significantly at 2 years (p = 0.019) and 5 years (p = 0.001). Liver biopsy at the end of the study showed no evidence of hepatic fibrosis caused by deferiprone. Cardiac studies showed no overall change in left ventricular ejection fraction but a significant improvement in isovolumic relaxation time (p = 0.045). We conclude that in this albeit small group of thalassaemia major patients, deferiprone was a safe long-term method of iron chelation. In a minority, higher doses of deferiprone or a combination with desferrioxamine would be needed to lower liver iron below 15 mg/g.

Comparison of the systemic levels of inflammatory markers after percutaneous coronary intervention with bare metal versus sirolimus-eluting stents.

BACKGROUND Percutaneous coronary intervention (PCI) with bare metal stent (BMS) deployment causes plaque disruption and a rise in systemic levels of C-reactive protein (CRP), interleukin (IL)-6, and monocyte chemoattractant protein (MCP)-1. Our aim is to study whether PCI with sirolimus-eluting stent (SES) use attenuates this response. METHODS Patients with stable angina undergoing single-vessel PCI were enrolled in a randomized, open-label fashion into a BMS group or an SES group. Blood samples were drawn pre-PCI, 24 hours post-PCI, and 30 days post-PCI. Systemic concentrations of CRP, IL-6, and MCP-1 were measured at all time points. RESULTS In total, 41 patients were enrolled (21 in the BMS group and 20 in the SES group). The baseline plasma concentrations of all markers were comparable between groups. At 24 hours, the mean plasma CRP concentration in the SES group was 20.21 mg/dL versus 8.95 mg/dL in the BMS group (P = 0.15). The mean plasma IL-6 concentration at 24 hours was 25.41 pg/mL in the SES group versus 17.44 pg/mL in the BMS group (P = 0.17). The mean plasma MCP-1 concentration at 24 hours was 382.38 pg/mL in the SES group versus 329.04 pg/mL in the BMS group (P = 0.2). At 30 days, plasma concentrations of all three markers decreased to similar values between groups. CONCLUSIONS The use of SES did not inhibit the rise in systemic concentrations of CRP, IL-6, and MCP-1 at 24 hours or 30 days post-PCI, compared with BMS. Moreover, at 24 hours, there was a trend for higher systemic levels of all proinflammatory markers in the SES group compared with the BMS cohort.

First Report of Nocardia asiatica Presenting as an Anterior Mediastinal Mass in a Patient with Myasthenia Gravis: A Case Report and Review of the Literature.

The spectrum of infections with Nocardia spp. is heterogeneous. It has classically been associated with lung, brain, or skin involvement. We describe an unusual presentation of Nocardia asiatica (N. asiatica) in an Iraqi patient with myasthenia gravis suffering from a disseminated infection and presenting with an anterior mediastinal cystic mass. N. asiatica has only been three times described outside Japan and Thailand, and the rarity of this entity deserves this communication.

Cardiac tamponade caused by polymicrobial Gram-negative organisms

Polymicrobial gram-negative pericarditis is a rare entity. We describe the first case of suppurative pericarditis with Citrobacter diversus and Proteus mirabilis.

Posttransfusion graft-versus-host disease in two immunocompetent patients

Graft-versus-host disease may occur in certain immunocompromised patients after a blood transfusion. The disease is characterized by fever, a skin eruption, gastrointestinal disturbances, liver dysfunction, and bone marrow aplasia. Two cases of fatal graft-versus-host disease are reported. Both patients were immunocompetent and had received transfusions of nonirradiated blood from their children during surgery. The importance of preventing this complication by irradiating blood products given to patients by their first-degree relatives is underscored.

Asymptomatic Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia that could present as angina, acute myocardial infarction, or even sudden death. It occurs more commonly in women and it has been associated with autoimmune and collagen vascular diseases. The management and prognosis in these patients depend on the initial clinical presentation and the extent of dissection. In this article, we report 2 cases of asymptomatic SCAD that were diagnosed on routine preoperative evaluation. The management options and clinical implications are discussed. Copyright

The interaction of gender and clinical risk profile in patients referred for exercise nuclear imaging versus exercise echocardiography

BACKGROUND Exercise myocardial perfusion imaging (E-MPI) and exercise echocardiography (E-Echo) are thought to be compatible for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). The interaction of gender and clinical risk profile in the referral of patients to either of these two imaging modalities has not been well studied. METHODS AND RESULTS This was a prospective study of 922 consecutive patients who were referred for either E-MPI (331 patients) or E-Echo (591 patients) at the American University of Beirut Medical Center in the year of 2008. Men undergoing E-MPI had a higher risk profile than those undergoing E-Echo. They were older (58±12 years versus 55±12 years, p=0.002) and had a higher prevalence of multiple (>2) CAD risk factors (55% versus 37%, p<0.001) as well as a higher prevalence of prior PCI (22% versus 15%, p=0.017) or CABG (12% versus 7%, p=0.016). Furthermore, they achieved lower METS in their exercise (9.4±2.0 versus 10.4±2.3, p<0.001) and had a higher incidence of ischemia and on their scans (16% versus 9.1%, p=0.008). In contrast, women undergoing E-MPI had a similar profile to those undergoing E-Echo in terms of prevalence of risk factors, prior history of coronary events and the prevalence of ischemia or impaired ejection fraction on their scans. CONCLUSION There is an important interaction between gender and clinical risk profile in patients undergoing E-MPI versus E-Echo. In men, E-MPI seems to be the preferred test for the higher risk profile patients, whereas in women the two tests are interchangeable.