Should we wait until severe pulmonary hypertension develops? Efficacy of percutaneous mitral balloon valvuloplasty in patients with severe pulmonary hypertension: A subgroup analysis of our experience

Background: The primary goal of this study is to evaluate the immediate and long-term ef­fects of percutaneous mitral balloon valvuloplasty (PBMV) on patients with rheumatic mitral stenosis (MS) complicated with severe pulmonary hypertension (PH). Methods: The study population consisted of 85 patients with MS complicated with severe PH (systolic pulmonary pressure > 75 mm Hg). PBMV was performed with Inoue balloon technique. Clinical and echocardiographic follow-up was scheduled at 6 months and 1 year and yearly thereafter. Results: Mitral valve area (MVA) was increased (pre-PBMV MVA was 1.03 ± 0.21 cm2, post-PBMV MVA 1.89 ± 0.34 cm2, p < 0.001) significantly. The mean and the maximum transmitral pressure gradient significantly decreased (pre-PBMV mean transmitral gradient was 18.47 ± 6.59 mm Hg, post-PBMV 6.84 ± 3.84 mm Hg, p < 0.001, pre-PBMV maximum transmitral pressure gradient was 27.6 ± 8.38 mm Hg, post-PBMV 12.68 ± 4.74 mm Hg, p < 0.001). Systolic pulmonary artery pressure (SPAP) significantly decreased (pre-PBMV 89.9 ± 23.38 mm Hg, post-PBMV 54.5 ± 14.6 mm Hg, p < 0.001). Two patients underwent surgery due to rupture of anterior mitral leaflet. There was no peri-procedural mortality. The procedure time was 29.12 ± 11.37 min. Follow-up duration was 108.2 ± 31.4 months. One patient died due to heart failure. One patient underwent re-PBMV and 7 patients mitral valve replacement. At the last follow-up, MVA still remained high (1.52 ± 0.34 cm2) and mean transmitral pressure gradient was low (9.2 ± 5.7 mm Hg). SPAP was 56.5 ± 20.8 mm Hg which was the same as after PBMV. Conclusions: PBMV in patients with MS with severe PH is an effective therapy with low procedure time. However, it is recommended to perform PBMV before developing severe PH

Effects of Nebivolol on Endothelial Function and Exercise Parameters in Patients with Slow Coronary Flow

Objective Earlier studies have reported that a decrease in exercise capacity might indicate endothelial dysfunction. However, the effects of improvement of endothelial functions on exercise capacity have not been evaluated. The aim of the present study is to investigate the effects of nebivolol on flow-mediated dilatation (FMD), and on the exercise capacities of the patients with slow coronary flow (SCF). Methods The study population included 25 subjects with SCF (Group 1) documented by the thrombolysis in myocardial infarction (TIMI) frame count, and 25 control group (Group 2) subjects with normal coronary angiography, for a total of 50 subjects who underwent coronary angiography due to several indications and had no coronary lesion. The TIMI frame count (TFC) values of the subjects in Group I for left anterior descending artery, right coronary, and circumflex coronary artery were 61.8 ± 30.6, 37.2 ± 17.4, and 34.6 ± 17.4, respectively. All the subjects received nebivolol 5 mg/day. Results At the end of the first month of FMD, the mean exercise duration (MED) and the Duke Scores of the patients with SCF were significantly higher than the baseline values. However, the values by the sixth month did not differ from that at the first month. Although a numerical improvement compared to the baseline values was observed for the subjects in Group 2 by the measurements at the end of the first and the sixth month, this difference was not statistically significant. Conclusions Nebivolol treatment increases FMD in the subjects with SCF. The difference in the exercise parameters of these subjects is particularly dramatic, and such an outcome may indirectly indicate long-term improvement in endothelial function

Short-term outcome of early electrical cardioversion for atrial fibrillation in hyperthyroid versus euthyroid patients*

Background: Atrial fibrillation (AF) is the most common cardiac complication of hyperthyroidism. The influence of the time of cardioversion on hyperthyroidism-induced AF remains unclear. The aim of this study was to compare short-term outcomes of early electrical cardioversion for AF in hyperthyroid and euthyroid patients. Methods and Results: Sixty-seven subjects with persistent AF (duration, 10 days–12 months) were divided into two groups according to thyroid function: Euthyroid (Group 1, n = 36, female/male: 23/13, mean age: 61.77 ± 10.45 years) and hyperthyroid (Group 2, n = 31, female/male: 10/21, mean age: 65.43 ± 6.40 years). Two patients were excluded for unsuccessful cardioversion (one in each group). In Group 2, 19 patients had clinical and 11 had subclinical hyperthyroidism. Following transthoracic and transesophageal echocardiography, cardioversion was performed until the highest energy was reached (270 J) or until sinus rhythm was achieved. AF recurrence was detected in 13 of 35 patients (37.1%) in Group 1 and in 11 of 30 patients (36.9%) in Group 2 (p = 0.96) at one month. Recurrence rate was higher in the clinical hyperthyroid patients than in the subclinical hyperthyroid patients (52.6% vs 9.1%, p = 0.021), but neither the clinical nor the subclinical hyperthyroid subgroups were significantly different from Group 1 in terms of recurrence rate (p = 0.27 and p = 0.13, respectively). Conclusions: Electrical cardioversion should be performed for patients with persistent AF and hyperthyroidism as soon as possible. (Cardiol J 2012; 19, 1: 53–60

Predictive value of atrial electromechanical delay for atrial fibrillation recurrence

Background: We investigated the predictive value of atrial electromechanical delay (AEMD) for recurrence of atrial fibrillation (AF) at 1-month after cardioversion.Methods: Seventy-seven patients with persistent AF were evaluated and finally 50 patients (12 men, 38 women) were included. All patients underwent transthoracic electrical DC cardioversion under amiodarone treatment. AEMD was measured as the time interval from the onset of the P wave on electrogram (ECG) to the beginning of late diastolic wave (Am) from the ventricular annulus and atrial walls on tissue Doppler imaging, in the apical 4-chamber view 24 h after cardiversion. P wave maximum-duration (Pmax), P wave minimum-duration (Pmin) and P wave dispersion-duration (Pdis) were calculated on the 12-lead ECG at 24-h postcardioversion. We followed the heart rate and rhythm by 12-lead ECG at 24-h, 1-week and 1-month.Results: At 1-month follow-up after cardioversion, 28 (56%) patients were in sinus rhythm (SR), whereas 22 (44%) patients reverted to AF. The AEMD durations were longer in AF group than SR group (p < 0.001) and were signifi cantly correlated with Pmax and Pdis (p < 0.001 for both). For AF recurrence; duration of AF, left atrial (LA) diameter, maximum LA volume index, mitral A velocity and LA lateral AEMD were significant parameters in univariate-analysis, however LA lateral AEMD was the only significant parameter in multivariate-analysis (OR: 1.46; 95% CI 1.02–2.11; p = 0.03).Conclusions: Our results suggest that AEMD is associated with an increased risk of recurrence of AF within 1-month. These data may have implications for the identification of patients who are most likely to experience substantial benefit from cardiversion therapy for AF

A Rare Side Effect due to TNF-Alpha Blocking Agent: Acute Pleuropericarditis with Adalimumab

Tumor necrosis factor-alpha antagonism is an important treatment strategy in patients with rheumatoid arthritis, psoriatic arthritis, vasculitis, and ankylosing spondylitis. Adalimumab is one of the well-known tumor necrosis factor-alpha blocking agents. There are several side effects reported in patients with adalimumab therapy. Cardiac side effects of adalimumab are rare. Only a few cardiac side effects were reported. A 61-year-old man treated with adalimumab for the last 6 months due to psoriatic arthritis presented with typically acute pleuropericarditis. Chest X-ray and echocardiography demonstrated marked pericardial effusion. Patient was successfully evaluated for the etiology of acute pleuro-pericarditis. Every etiology was excluded except the usage of adalimumab. Adalimumab was discontinued, and patient was treated with 1200 mg of ibuprofen daily. Control chest X-ray and echocardiography after three weeks demonstrated complete resolution of both pleural and pericardial effusions. This case clearly demonstrated the acute onset of pericarditis with adalimumab usage. Acute pericarditis and pericardial effusion should be kept in mind in patients with adalimumab treatment

Atrial Strain and Strain Rate: A Novel Method for the Evaluation of Atrial Stunning

Abstract Background: Atrial fibrillation (AF) is the most common arrhythmia seen in adults. Atrial stunning is defined as the temporary mechanical dysfunction of the atrial appendage developing after AF has returned to sinus rhythm (SR). Objectives: We aimed to evaluate atrial contractile functions by strain and strain rate in patients with AF, following pharmacological and electrical cardioversion and to compare it with conventional methods. Methods: This study included 41 patients with persistent AF and 35 age-matched control cases with SR. All the AF patients included in the study had transthoracic and transesophageal echocardiography performed before and after. Septum (SEPsSR), left atrium (LAsSR) and right atrium peak systolic strain rate (RAsSR) were defined as the maximum negative value during atrial contraction and septum (SEP&#949;), left atrium (LA&#949;) and right atrium peak systolic strain (RA&#949;) was defined as the percentage of change. Parameters of two groups were compared. Results: In the AF group, 1st hour and 24th hour LA&#949;, RA&#949;, SEP&#949;, LAsSR, RAsSR, SEPsSR found to be significantly lower than in the control group (LA&#949;: 2.61%±0.13, 3.06%±0.19 vs 6.45%±0.27, p<0.0001; RA&#949;: 4.03%±0.38, 4.50%±0.47 vs 10.12%±0.64, p<0.0001; SEP&#949;: 3.0%±0.22, 3.19%±0.15 vs 6.23%±0.49, p<0.0001; LAsSR: 0.61±0.04s-1, 0.75±0.04s- 1 vs 1.35±0.04s-1, p<0.0001; RAsSR: 1.13±0.06s-1, 1.23±0.07s-1 vs 2.10±0.08s- 1, p<0.0001; SEPsSR: 0.76±0.04s- 1, 0.78±0.04s- 1 vs 1.42±0.06 s- 1, p<0.0001). Conclusion: Atrial strain and strain rate parameters are superior to conventional echocardiographic parameters for the evaluation of atrial stunning in AF cases where SR has been achieved

Atrial Strain and Strain Rate: A Novel Method for the Evaluation of Atrial Stunning

Abstract Background: Atrial fibrillation (AF) is the most common arrhythmia seen in adults. Atrial stunning is defined as the temporary mechanical dysfunction of the atrial appendage developing after AF has returned to sinus rhythm (SR). Objectives: We aimed to evaluate atrial contractile functions by strain and strain rate in patients with AF, following pharmacological and electrical cardioversion and to compare it with conventional methods. Methods: This study included 41 patients with persistent AF and 35 age-matched control cases with SR. All the AF patients included in the study had transthoracic and transesophageal echocardiography performed before and after. Septum (SEPsSR), left atrium (LAsSR) and right atrium peak systolic strain rate (RAsSR) were defined as the maximum negative value during atrial contraction and septum (SEPε), left atrium (LAε) and right atrium peak systolic strain (RAε) was defined as the percentage of change. Parameters of two groups were compared. Results: In the AF group, 1st hour and 24th hour LAε, RAε, SEPε, LAsSR, RAsSR, SEPsSR found to be significantly lower than in the control group (LAε: 2.61%±0.13, 3.06%±0.19 vs 6.45%±0.27, p<0.0001; RAε: 4.03%±0.38, 4.50%±0.47 vs 10.12%±0.64, p<0.0001; SEPε: 3.0%±0.22, 3.19%±0.15 vs 6.23%±0.49, p<0.0001; LAsSR: 0.61±0.04s-1, 0.75±0.04s- 1 vs 1.35±0.04s-1, p<0.0001; RAsSR: 1.13±0.06s-1, 1.23±0.07s-1 vs 2.10±0.08s- 1, p<0.0001; SEPsSR: 0.76±0.04s- 1, 0.78±0.04s- 1 vs 1.42±0.06 s- 1, p<0.0001). Conclusion: Atrial strain and strain rate parameters are superior to conventional echocardiographic parameters for the evaluation of atrial stunning in AF cases where SR has been achieved