An Unusual Association of Coronary Cameral Fistula and Mid-Cavitary Hypertrophic Cardiomyopathy

The presence of both myocardial hypertrophy and coronary-to-cameral fistula has been reported previously. However, the exact mechanisms are not clear. Herein, we reported a patient with mid-cavitary hypertrophic cardiomyopathy and concomitant connections between coronary arteries and left ventricular cavity

An Old Complication Welcomes Us in the Modern Era: Lingual Hematoma During Thrombolytic Therapy

Lingual hematoma is a rare but potentially life-threatening clinical condition. Securing the airway and urgent treatment for underlying reasons are key management steps. We reported a case to illustrate the management of a lingual hematoma after rescue thrombolysis for a ST-segment elevation myocardial infarction (STEMI) patient

Scary Acute Left Main Coronary Artery Thrombus as an Initial Presentation of a Hereditary Thrombophilia: When to Go Out of Routine?

Patients with either hereditary or acquired thrombophilia can present with arterial and venous thrombotic complications. However, it is unclear to whom the thrombophilia panel should be assessed, particularly in patients presenting with a common cardiovascular risk factor and acute coronary thrombus. Herein, we presented the management of an active smoker female patient who presented to our emergency room with inferior acute ST-segment elevation myocardial infarction, and hereditary thrombophilia has been diagnosed due to the presence of substantial left main coronary artery thrombus

Aggressive Treatment of Refractory Coronary Artery Vasospasm in a Patient with Malignant Ventricular Tachyarrhythmia and Cardiac Arrest

Coronary artery vasospasm (CAVS) is a clinical entity that can cause angina, but also unstable angina pectoris, acute myocardial infarction, fatal arrhythmias, and sudden death. Although it is a condition that is usually controlled with medical treatment, more aggressive treatments may rarely be required. In this case, the patient with a known diagnosis of CAVS had multiple arrests despite optimal medical treatment. We observed that fatal arrhythmias persisted in the Implantable Cardioverter Defibrillator (ICD) records, even though we implanted a stent and gave the patient maximal medical treatment. We performed sympathectomy as a last resort and we did not detect any recurrence in the 6-month follow-up of the patient. ICD implantation and sympathectomy should always be considered in resistant CAVS cases

Atriyal Fibrilasyon Gelişiminde Atriyal Fibrozisin Rolü ve Pulmoner Ven İzolasyonu Başarısına Etkisi

Atrial fibrillation (AF) is initiated and maintained by the complex interaction of triggers and atrial substrate. Structural (atrial fibrosis), electrical and contractile remodelling play major role in the development of a vulnerable atrial substrate for AF. Serum transforming growth factor (TGF)-ß1 is the key mediator and related to the degree of atrial fibrosis. Although pulmonary vein isolation (PVI) is an effective therapetic method to eliminate triggers in the pathogenesis, the impact of atrial substrate on the PVI success remains unclear. In this study, we aimed to investigate the relation of serum TGF-ß1 level and degree of left atrium (LA) fibrosis using delayed-enhanced magnetic resonance imaging (DE-MRI) and effects on the success of PVI in patients with lone paroxysmal AF. A total of 41 symptomatic lone paroxysmal AF patients (24 male, 58.5%; mean age: 49.2±7.6 years) underwent cryoballoon based catheter ablation. Cardiac DE-MRI to quantify atrial fibrosis, serum TGF- ß1 levels, clinical and echocardiographic data were collected before cryoballoon ablation. Postablation blanking period was observed for 3 months. Duration of the AF symptoms was median 60 months and mean EHRA score was 3.0±0.55. Mean LA anteroposterior diameter was 37.4±3.3 mm in all patients. DE-MRI revealed left atrial fibrosis in 27 (65.9%) patients [13 (31.7%) mild, 9 (22%) moderate and 5 (12.2%) severe fibrosis] with the median enhancement of 5% of the LA. Totally 179 PVs were successfully isolated with no major complication. During blanking period, 10 (24.4%) patients developed early recurrence. At a median follow-up time of 18 months, 32 patients (78.1%) remained free of AF recurrence. While only serum TGF-ß1 level (OR: 1.01, 95% CI: 1.004-1.016, p=0.008) found as the predictor of the presence of LA fibrosis; both serum TGF-ß1 level (ß+SH=0.001±0,0002, p=0.001) and duration of AF episode (ß+SH=6.092±1.183, p=0.001) were found as the predictors of the extent of LA fibrosis. In multivariate cox regression analysis, extent of the LA fibrosis (HR: 1.127, 95% CI: 1.034-1.229, p= 0.007) and early AF recurrence (HR: 1.442, 95% CI: 1.087-1.913, p= 0.011) were found as the independent predictors of AF recurrence. Serum TGFß-1 level of >15.894 pg/mL predicted the presence of LA fibrosis with a sensitivity of 70.37% and specificity of 100%. Also LA fibrosis extent of >20% predicted the development of AF recurrence with sensitivity of 100% and specificity of 93.75 %. Left atrial fibrosis determined by DE-MRI and increased serum TGFß-1 level play major role in LA structural remodelling and has an impact on the success of PVI. Presence and extent of LA fibrosis using DE-MRI may help select appropriate patients for catheter based AF ablation and improve procedural outcome.Atriyal fibrilasyon (AF) tetikleyiciler ve atriyal substrat arasındaki karmaşık ilişki sonucunda başlamakta ve devam etmektedir. Yapısal (atriyal fibrozis), elektriksel ve kontraktil yeniden şekillenme AF için hassas atriyal substrat oluşumunda önemli rol oynar. Serum dönüştürücü büyüme faktörü (TGF)-ß1 atriyal fibrozis gelişiminde anahtar molekül olup fibrozis derecesi ile ilişkilidir. Pulmoner ven izolasyonu (PVİ) patogenezde yer alan tetikleyicilerin ortadan kaldırılmasında etkili tedavi yöntemi iken, atriyal substratın PVİ başarısına etkisi net değildir. Bu çalışmanın amacı lone paroksizmal AF hastalarında serum TGF-ß1 düzeyi ile manyetik rezonans görüntülemede geç kontrast tutulumu (DE-MRG) tekniği ile saptanan sol atriyal (SolA) fibrozis derecesi ilişkisi ve PVİ başarısına etkisinin araştırılmasıdır. Toplam 41 semptomatik lone paroksizmal AF hastasına (24 erkek, %58.5; ort yaş: 49.2±7.6 yıl) kriyobalon ile kateter ablasyon yapıldı. Kriyoablasyon öncesi tüm hastalara ait DE-MRG ile atriyal fibrozis değerlendirilmesi, serum TGF- ß1 düzeyi, klinik ve ekokardiyografik veriler kayıt edildi. Ablasyon sonrası ilk 3 ay kör dönem olarak tanımlandı. Hastaların ortanca 60 aydır AF semptomları olup, ortalama EHRA skoru 3.0±0.55 bulundu. Çalışma grubunun ortalama SolA ön-arka çapı 37.4±3.3 mm ölçüldü. DE-MRG ile 27 (%65.9) hastada [13 (%31.7) hafif, 9 (22%) orta derece ve 5 (12.2%) ciddi fibrozis) SolA fibrozis saptandı ve ortanca geç kontrast tutulumu %5 hesaplandı. Toplam 179 PV majör komplikasyon gelişmeden başarı ile izole edildi. Kör dönemde 10 (%24.4) hastada erken rekürrens gelişti. Ortanca 18 aylık izlemde 32 (%78.1) hasta AF'siz izlendi. Sadece serum TGF-ß1 düzeyi (OR: 1.01, %95 GA: 1.004-1.016, p=0.008) SolA fibrozis varlığının bağımsız öngördürücüsü iken; hem serum TGF-ß1 düzeyi (ß+SH=0.001±0,0002, p=0.001) hem de AF atağının süresi (ß+SH=6.092±1.183, p=0.001) SolA fibrozis yaygınlığının bağımsız öngördürücüleri olarak bulundu. Çok değişkenli Cox regresyon analizinde, SolA fibrozisinin yaygınlığı (HR: 1.127, %95 GA: 1.034-1.229, p= 0.007) ve erken rekürrens (HR: 1,442, %95 GA: 1.087-1.913, p= 0.011) AF rekürrensinin bağımsız öngördürücüleri olarak saptandı. Serum TGFß-1 düzeyi >15.894 pg/mL alındığında, %70.37 duyarlılık ve % 100 özgüllük ile SolA fibrozis varlığını öngördüğü gözlendi. SolA fibrozis alan genişliği >%20 alındığında %100 duyarlılık ve %93.75 özgüllük ile rekürrens gelişimini öngördüğü gözlendi. DE-MRG ile saptanan SolA fibrozis ve artmış serum TGFß-1 düzeyi SolA yapısal yeniden şekillenmede önemli role sahiptir ve PVİ başarısını etkilemektedir. DE-MRG ile saptanan SolA fibrozis varlığı ve yaygınlığı kateter bazlı AF ablasyonu için hasta seçiminde ve işlem başarısının arttırılmasında yardımcı olabilir