Biomedical subjects
Publications and source records attributed to Basri Amasyali.
Variant angina is generally a benign disease with self limiting symptoms. But in some cases serious ventricular arrhythmias which can lead to death can be seen. In this paper we present a case of variant angina who subsequently developed polymorphic ventricular tachycardia and was treated successfully with long acting nitrate and calcium channel blockade therapy.
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QRS voltage and cycle length alternation can be seen during supraventricular re-entrant tachycardias, especially in atrioventricular (AV) re-entrant tachycardia. We present a case of a 20-year-old man, in which AV nodal re-entrant tachycardia (AVNRT) shows alternation of QRS voltage and cycle length, as well as right bundle branch block aberration due to a re-entrant circuit using two distinct, beat-to-beat alternating slow AV nodal pathways antegradely and a single fast pathway retrogradely. Although more than one antegrade slow pathway exists, creation of a single lesion at the right posterior atrial septum using the conventional right-sided approach successfully eliminated AVNRT.
Permanent form of junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular re-entrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are localized in the posteroseptal zone. Despite the high success rate, failure may occur during endocardial radiofrequency catheter ablation due to epicardial insertion of the accessory pathway. We report a case of PJRT in a 25-year-old man in whom the accessory pathway was located epicardially in the posteroinferior region and ablated from within the middle cardiac vein by radiofrequency catheter ablation.
The incidence of atrial fibrillation is higher in patients with VVI pacing mode than DDD pacing mode, but the likely mechanism is not clearly understood. We aimed to evaluate whether short-term VVI pacing increases inhomogeneous atrial conduction by using P-wave dispersion. Forty-seven patients (32 men, 15 women, mean age 54 +/- 13 years) with DDD pacemakers were enrolled in this study. Twelve-lead surface ECGs were obtained in all patients during VDD pacing after an observation period of 1 week. The mode was then changed to VVI and 12 lead surface ECGs were obtained after another 1-week observation period. P-wave durations were calculated in all 12 leads in both VDD and VVI pacing modes. The difference between the maximum and the minimum P-wave duration was defined as the P-wave dispersion (PWD = P(max) - P(min)). P-wave maximum duration (P(max)) calculated in VVI pacing mode was significantly longer than in VDD pacing mode (128 +/- 19 vs 113 +/- 16 ms, P < 0.001). There was no significant difference in the P-wave minimum durations (80 +/- 13 ms vs 79 +/- 12 ms, P = 0.7) between VVI pacing and VDD pacing. The P-wave dispersion value was higher in the VVI pacing mode than in the VDD pacing mode (48 +/- 8 ms vs 34 +/- 7 ms, P < 0.001). Short-term VVI pacing induces prolongation of P(max) and results in increased P-wave dispersion, which might be responsible for the development of atrial fibrillation more frequently in these patients than in those with the VDD pacing mode.
Coarctation of the aorta has been found at necropsy in approximately 1 of every 1550 individuals. The most common location for segmental coarctation (juxtaductal) is the attachment of the ductus arteriosus to the thoracic aorta, which accounts for 98% of focal lesions. Less commonly, a relatively long segment of constriction extends beyond the left subclavian artery. When longer segments of the aorta are narrowed, the term "hypoplasia" is often used. Aortic hypoplasia, an exceedingly rare cardiovascular anomaly, has been described in all portions of the thoracic and abdominal aorta. In the current case report, we described a 21-year-old man presenting with severe hypertension in whom the diagnosis of hypoplasia of the descending thoracic and abdominal aorta was made using with magnetic resonance imaging.
BACKGROUND: Reduced heart rate recovery (HRR) in coronary artery disease (CAD) is predictive of increased cardiovascular mortality and is related to reduced parasympathetic tonus. OBJECTIVE: To investigate HRR and heart rate variability (HRV) measured at steady state condition and the relationship between these two parameters in CAD. MATERIALS AND METHODS: In our study, we enrolled 33 (28 males, mean age 52.4 +/- 9.6 years) patients with CAD who did not have heart failure, atrial fibrillation, pacemaker, and any disease state that could affect the autonomic functions and 38 age-matched healthy subjects (21 males, mean age 48.3 +/- 7.8 years). All the patients underwent submaximal treadmill exercise testing (Bruce protocol). HRR was calculated by subtracting the heart rate values at the 1st, 2nd, and 3rd minutes of the recovery phase from the peak heart rate (HRR(1), HRR(2), HRR(3)). Before exercise testing, short-term steady state HRV analyses of all subjects were obtained with the time- and frequency-domain methods and were correlated to HRR. For frequency-domain analysis, low-frequency HRV (LF, 0.004-0.15 Hz), high-frequency HRV (HF, 0.15-0.5 Hz), and LF/HF ratio were measured for 5 minutes in the morning. For time-domain analysis, standard deviation of the normal-to-normal NN intervals (SDNN), square root of the mean squared differences of successive N-N intervals (RMSSD), and proportion derived by dividing the number of interval differences of successive N-N intervals greater than 50 ms by the total number of N-N intervals (pNN50) were obtained. Only HRR(3) was used for the correlation analysis. RESULTS: In CAD groups, the HF, an indicator of parasympathetic activation, was significantly reduced, whereas the LF and LF/HF values, which are indicators of sympathetic activity, were increased (P = 0.0001 for each parameter). The time-domain parameters SDNN, RMSSD, and pNN50 were significantly reduced in the patient group (P = 0.0001, P = 0.009, and P = 0.0001, respectively). Similar to the HRV parameters, the HRR(1), HRR(2), and HRR(3) values were significantly reduced in the patient group (P = 0.0001 for each parameter). We observed a significant negative correlation between HRR(3) and LF (r =-0.67, P = 0.0001) and between HRR(3) and LF/HF (r =-0.62, P < 0.0001), while there was a significant positive correlation between HRR(3) and HF, SDNN, RMSSD, and pNN50 (r = 0.69, P = 0.0001; r = 0.41, P = 0.0001; r = 0.31, P = 0.008; and r = 0.44, P = 0.0001). CONCLUSIONS: HRR and HRV are significantly reduced in CAD. The reduction in HRR is parallel to the changes in HRV parameters. HRR, which can be measured easily in the recovery phase of exercise testing, can be used to detect the depression of parasympathetic tonus and to evaluate the basal autonomic balance in this patient group.
BACKGROUND: Paroxysmal atrial fibrillation (AF) recurs in up to one-third of patients with atrioventricular nodal reentrant tachycardia (AVNRT) treated with slow pathway ablation. Therefore, identification of patients at risk for recurrence of AF after slow pathway ablation is important because of the necessity for additional therapies. The purpose of this study was to determine whether successful slow pathway ablation influences P wave parameters and whether these parameters predict the recurrence of paroxysmal AF in patients with both AVNRT and paroxysmal AF after ablation. METHODS: Thirty-six patients with AVNRT and documented paroxysmal AF (Group 1) were compared to 36 age-matched controls with AVNRT only (Group 2). P wave durations and P dispersion were measured before and after ablation. RESULTS: No significant differences were observed between P wave parameters observed before and after ablation. Maximum P wave durations (Pmax) and P dispersion (Pdisp) were significantly higher in Group 1 than in Group 2 (P < 0.001 for both) whereas minimum P wave durations did not differ between groups, both before and after ablation. Ten patients (28%) in Group-1 had recurrence of AF during a mean follow-up of 34 +/- 11 months. Univariate predictors of AF recurrence were Pdisp > or =35.5 ms (P < 0.010), left atrial diameter >40 mm (P < 0.010), mitral or aortic calcification (P < 0.010), Pmax > or =112 ms (P < 0.050), valvular heart disease (P < 0.050), and atrial vulnerability (induction of AF lasting >30 second) after ablation (P < 0.050). However, only Pdisp > or =35.5 ms (P < 0.050) and left atrial diameter >40 mm (P < 0.010) were independent predictors of AF recurrences. CONCLUSION: This study suggests that P wave dispersion could identify patients with AVNRT susceptible to recurrence of AF after slow pathway ablation.
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BACKGROUND: Prolongation of P-wave times and increase of P-wave dispersion (PWD) were shown to be independent predictors of atrial fibrillation (AF). Angiotensin II receptor blockers (AARBs) and angiotensin-converting enzyme inhibitors (ACEIs) have beneficial effects on atrial conduction times. However, there are not enough data about the comparative effects of those drugs on PWD. HYPOTHESIS: We aimed to compare the effects of telmisartan and ramipril on PWD after 6-month treatment in hypertensive patients. METHODS: In all, 100 newly diagnosed hypertensive patients were enrolled in the study and were randomly assigned to two groups. Group 1 and Group 2 each consisted of 50 patients, taking daily doses of 80 mg telmisartan and 10 mg ramipril, respectively. Twelve-lead surface electrocardiograms (ECG) were recorded from all patients before and after 6-month drug therapy. The P-wave duration (Pdur) measurements were calculated from the 12-lead surface ECG. RESULTS: When pretreatment PWD and Pmaximum values were compared with post-treatment values, a statistically significant decrease was found in both groups after 6 months (Group 1 and 2; p < 0.001 for PWD and Pmaximum). P-wave dispersion and Pmaximum values after treatment in Group 1 were statistically significantly lower than those in Group 2 after the 6-month treatment period (p = 0.01 for PWD; p = 0.008 for Pmaximum). CONCLUSIONS: Telmisartan has a much greater lowering effect on PWD and Pmaximum values than ramipril. This finding may be important in the prevention of AF in hypertensive patients.
The onset of recurrent or sustained atrial fibrillation (AF) is common during electrophysiological (EP) studies of accessory pathways (AP). We report our experience in patients with Wolff-Parkinson-White (WPW) syndrome in whom AF with rapid antegrade conduction over the AP occurred during an EP study and mapping and ablation were done during sustained AF, as compared to patients ablated during sinus rhythm. The study group consisted of 18 patients (group 1) with WPW syndrome who underwent catheter ablation during pre-excited AF. Two hundred and sixty-three patients, comparable for clinical characteristics, whose manifest APs were ablated under sinus rhythm formed the control group (group 2). Bipolar electrogram criteria recorded from the ablation catheter showing early ventricular activation relative to the delta wave on the surface ECG and AP potentials preceding the onset of ventricular activation were used as targets for ablation. Clinically documented atrial fibrillation was significantly more frequent and antegrade ERP of AP was significantly shorter in group 1 than in group 2 (39% vs 14%, P=0.014 and 268+/-37 vs 283+/-16, P<0.001, respectively). Procedure-related variables, acute success rates (17/18 [94%] in group 1, 251/263 [95%] in group 2; P>0.05) and late recurrence rates (0/18 [0%] in group 1 vs 5/263 [2%] in group 2; P>0.05) during a mean follow-up of 25+/-9 months (range 8-52 months) did not differ significantly. Our results show that both right- and left-sided accessory pathways can be mapped and ablated safely during pre-excited AF without delay, and that acute success and recurrence rates and long-term follow-up results are similar to those of pathways ablated during sinus rhythm.
We describe an asymptomatic 27-year-old man who presented a continuous murmur, and was found to have a tunnel between the aorta and the right atrium. Successful surgical treatment was performed. We emphasize the rarity of this condition, and discuss its major features.
INTRODUCTION: Clinical and electrophysiological characteristics of patients with atrioventricular nodal reentrant tachycardia (AVNRT) and paroxysmal atrial fibrillation (AF) have not been studied in a large patient cohort. We aimed to define the clinical features and cardiac electrophysiological characteristics of these patients, and to examine the incidence and identify predictors of AF recurrences after elimination of AVNRT. METHODS AND RESULTS: Thirty-six patients with AVNRT and documented paroxysmal AF (Group 1) and 497 patients with AVNRT alone undergoing ablation in the same period (Group 2) were studied. There were no significant differences between groups regarding clinical features, except age, which was higher in Group 1 (p<0.001). Presence of atrial vulnerability (induction of AF lasting>30 seconds) and multiple AH jumps (>or=50 ms) before ablation were significantly more prevalent in Group 1 (p<0.001, p=0.010 respectively). During follow-up of 34 +/- 11 months, AF recurred in 10 patients (28%) in Group 1, while 2 patients in Group 2 (0.4%) developed paroxysmal AF (p<0.001). Univariate predictors of AF were: left atrial diameter>40 mm (p=0.001), presence of mitral or aortic calcification (p=0.003), atrial vulnerability after ablation (p=0.015) and valvular disease (p=0.042). However, independent predictors of AF recurrences were left atrial diameter>40 mm (p=0.002) and the presence of atrial vulnerability after ablation (p=0.034). CONCLUSION: In patients with both AVNRT and paroxysmal AF, the recurrence rate of AF after elimination of AVNRT is 28%. Left atrial diameter greater than 40 mm and atrial vulnerability after elimination of AVNRT are independent predictors of AF recurrences in the long term.
BACKGROUND: Increased preprocedural C-reactive protein (CRP) levels in patients with acute myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI) may affect myocardial perfusion. Accordingly, this study was designed to investigate the impact of admission CRP levels on the development of poor myocardial perfusion after PCI in patients with acute MI. METHODS: The study population consisted of 75 patients (62 men, mean age, 61.6+/-6.68 years), who were admitted to our hospital with acute anterior MI and who underwent primary PCI in the left anterior descending coronary artery. All patients underwent stenting following balloon angioplasty. Myocardial perfusion was evaluated by using Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade (TMPG). Patients were divided into two groups according to TMPG after PCI. Group 1 consisted of 25 patients with TMPG 0-1 and group 2 comprised 50 patients with TMPG 2-3. Admission serum high sensitive CRP (hs-CRP) levels were analysed by using nephelometric method. RESULTS: Admission hs-CRP levels, pain to balloon time and white blood cell count (WBC) of patients in group 1 were significantly higher than those of the patients in group 2 (P<0.001; P<0.001; P=0.002, respectively). Univariate analysis identified ejection fraction, pain to balloon time, WBC and hs-CRP levels as the predictors of poor myocardial perfusion. In multivariate logistic regression analysis, hs-CRP levels and pain to balloon time were found to have statistically significant independent association with poor myocardial perfusion. Adjusted odds ratios were calculated as 1.85 for hs-CRP [P=0.003; 95% confidence interval (CI), 1.23-2.80] and 5.49 for pain to balloon time (P=0.04; 95% CI, 1.08-27.84). CONCLUSIONS: On admission, high CRP level in patients with acute MI undergoing primary PCI is likely to be in the causal pathway leading to the development of poor myocardial perfusion, especially when combined with prolonged pain to balloon time.
BACKGROUND: Statins exert a variety of favourable effects on the vascular system not directly related to their lipid lowering function known as pleiotropic effects. There are not enough data regarding the effects of prior statin use on coronary blood flow after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Accordingly, in the present study, we aimed to investigate the effects of prior statin use on coronary blood flow after primary PCI in patients with AMI using the Thrombolysis In Myocardial Infarction (TIMI) frame count method. METHODS: The study population consisted of 200 patients (161 men; mean age=62+/-7 years) referred to cardiology clinics with AMI who subsequently underwent successful primary PCI. The study population was divided into two groups according to statin use before primary PCI. Group 1 consisted of 98 patients (75 men; mean age=63+/-7 years) not taking statin and group 2 consisted of 102 patients (86 men; mean age=61+/-7 years) taking daily dose of at least 40 mg atorvastatin for at least 6 months. Coronary blood flow was determined by TIMI frame count method using the angiographic images obtained just after PCI and stenting. RESULTS: Only mean TIMI frame count was detected to be significantly lower in patients taking at least 40 mg atorvastatin for at least 6 months compared with that of the patients taking no statin (P<0.001). After confounding variables were controlled for, the mean TIMI frame count of patients in group 2 was significantly lower than that of the patients in group 1 (P=0.001). Pain to balloon time and vessel type were detected as important confounding variables of TIMI frame count after analysis of covariances. CONCLUSIONS: Prior statin use may improve coronary blood flow after PCI in patients with AMI, possibly by its beneficial effects on microvascular function.
OBJECTIVE: To evaluate ischemia in right ventricle (RV) in patients with small caliber of right coronary artery (RCA). PATIENTS AND METHODS: The study population consisted of 60 consecutive patients undergoing coronary angiography within 3 months. The patients were divided into three different groups according to lumen diameter of RCA and coronary dominance. Group 1, 2, and 3 consisted of patients with small diameter of RCA, dominant RCA, and dominant circumflex artery, respectively. RV ischemia was assessed by using pulse-wave tissue Doppler sampling obtained from RV free wall close to the lateral tricuspid annulus at the apical four-chamber view during dobutamine stress echocardiography (DSE). RESULTS: When the mean systolic velocity percentages of increase from low to peak dose dobutamine in patients with small RCA were compared to those of other groups, statistically significant difference was found between group 1 and the other groups (P = 0.007 for group 1 vs group 2; P = 0.01 for group 1 vs group 3). The mean systolic velocity at peak dobutamine dose of patients with small caliber of right coronary artery was statistically lower than the other groups (P = 0.001 for group 1 vs group 2, P < 0.001 group 1 vs group 3). CONCLUSIONS: There are a group of patients with small diameter of RCA causing probable ischemia in RV and small caliber of RCA can really matter in these patients.
BACKGROUND: Several studies demonstrated that P wave dispersion (PWD) increased after coronary occlusion. The effect of primary percutaneous coronary intervention (PCI) on PWD needs to be elucidated. METHODS: The study consisted of 125 patients with acute myocardial infarction (110 men, mean age 59.8+/-7.8 years) undergoing primary PCI. The patients were divided into three groups according to thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) after successful PCI. Groups 1 (n=12), 2 (n=9), and 3 (n=104) included the patients with TMPG 0/1, 2, 3, respectively. Electrocardiograms were obtained before and approximately 66+/-18 minutes after PCI. RESULTS: PWD and P(maximum) after PCI were significantly lower than the preintervention values (P<0.001 for both). When PWD and Pmaximum values after PCI were compared among groups, PWD and Pmaximum in groups 1 and 2 were found to be higher than those of group 3 (P<0.001 for PWD and Pmaximum). Atrial fibrillation (AF) occurred in 14 patients. Pmaximum and PWD in patients with AF were higher compared to those of the patients without AF (P<0.001 for both P wave parameters). Also more frequent AF attacks were observed in group 1 compared to group 3 (P<0.001). CONCLUSIONS: PWD and Pmaximum after primary PCI were lower compared to the preintervention values. Prolonged PWD in patients with poor myocardial perfusion can contribute to increased mortality, and also it can can be combined with ST segment resolution to predict clinical reperfusion and might help in predicting AF.
Radiofrequency catheter ablation or modification of the slow pathway is almost always performed on the right atrial side of the interatrial septum, however, this is not possible in rare cases. We evaluated the clinical and electrophysiological characteristics and long-term follow-up results of patients whose AVNRT could only be ablated from the left posterior atrial septum after repeated unsuccessful attempts on the right atrial side and to observe if they differ from those undergoing ablation with the conventional right-sided approach. Of 587 cases with symptomatic typical AVNRT, 9 patients (1.5%) in whom RF energy delivered to the right atrial septum with the integrated approach failed to ablate or modify the slow pathway were enrolled in the study group (group 1) while the others served as controls (group 2). There was no significant difference between the groups regarding clinical characteristics, dual AV nodal physiology, sinus cycle lengths, AH and HV intervals, procedural complication rates, or recurrence rates in the mean follow-up duration of 34 +/- 11 months. Only tachycardia cycle length (TCL) was significantly higher in group 1 than in group 2, which was mainly due to the difference in AH intervals (P < 0.001 for both). Slow pathway ablation was performed at the posteroseptal aspect of the mitral annulus in 6 and the midseptal aspect in 2 cases. In 1 case, attempts at ablation on the left atrial septum also failed. When the conventional right-sided approach fails to ablate or modify the slow pathway conduction, left-sided ablation can safely and effectively be employed, with success rates and long-term follow-up results comparable to the conventional right-sided approach.