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Background: Considering that ablation of atypical AVNRT may be unsuccessful after ablation at the right posterior septum, in this study, we aimed to present an optimal method for ablation of atypical AVNRT. Also, we evaluated the efficacy of this technique for preventing recurrences., Methods: This is a prospective, double-center study. It was conducted on 62 patients with atypical AVNRT referred for radiofrequency ablation. The patients were randomly divided into two groups before ablation: 1-Group A (n = 30): treated with conventional ablation at the anatomic area of the slow pathway; 2-Group B (n = 32): ablation was done 2 mm higher in the septum during fluoroscopy., Results: The mean age of patients in groups A and B were 54 ± 11.7 and 55 ± 12.2, respectively (P = 0.43). In group A, ablation was successful in 24 (80%) patients following right-sided slow pathway ablation, and the remaining patients required further treatment with either a left-side approach (N = 4, 13.3%) or ablation of additional regions (N = 2, 6.7%). In group B, ablation was successful in all patients. After a 48-month follow-up, recurrence of symptomatic atypical AVNRT was detected in 4 (13.3%) patients of group A and none of group B patients (p < 0.001)., Conclusion: In patients with atypical AVNRT, ablation 2 mm above the conventional area is more promising regarding success rate and recurrence of the arrhythmia., (© 2023. The Author(s).)

Background: More than 70% of thalassemia's major mortality is due to the cardiac complications of this syndrome, mostly consequent to myocardial Iron overload; therefore, evaluation of such complications is of utmost importance. T2*MRI is used to assess hepatic and myocardial Iron load in thalassemia patients, which is not always available. Signal-Averaged Electrocardiography is a rather easy method of evaluating major thalassemia patients regarding their risk for sudden cardiac death., Methods and Materials: In this cross-sectional study, 48 patients with thalassemia major underwent evaluation with electrocardiography, signal-averaged electrocardiography, echocardiography, T2*MRI, and ferritin level. The association of the existence of ventricular late potentials in SAECG and other cardiac variables was evaluated. Moreover, the association between myocardial and hepatic Iron load and cardiac characteristics was assessed., Results: 48 patients with a mean age of 30.31 ± 7.22 years old entered the study. 27 (56.3%) of the patients had ventricular late potentials, which were associated with myocardial dry Iron weight (P = 0.011). Nonspecific ST-T changes and premature atrial and ventricular contractions were seen more frequently in patients with late potentials (P = 0.002, 0.031, and 0.031, respectively). Patients with higher myocardial and hepatic Iron loads had longer QT c in their 12-lead surface electrocardiograms., Conclusion: Patients with ventricular late potentials assessed by SAECG had a higher myocardial Iron load. Higher myocardial Iron load is associated with higher cardiac complications in patients with beta-thalassemia major; therefore, SAECG can be used as a screening test for cardiac complications in beta-thalassemia major patients., (© 2022. The Author(s).)

Background: Electrocardiography (ECG) is now proposed as a simple and cost-effective tool to determine the location of arrhythmias before ablation. We aimed to examine the value of the QRS onset of outflow tract PVC in V1 and V2 leads recorded in fourth, third, and second intercostal spaces to differentiate two main origins for premature ventricular contraction (PVC) including right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT)., Methods: In this prospective cohort study, a total of 58 patients were studied, from whom a surface ECG was obtained using V1 and V2 leads in the fourth, third, and second intercostal spaces. ECG and Electrophysiology studie (EPS) data were then recorded and compared to determine the sensitivity and specificity of QRS onset in locating arrhythmias. The reciever operating characterictic (ROC) curve analysis was applied to test diagnostic performance., Results: Based on the time of PVC initiation in each of the V1 and V2 leads in the fourth intercostal space, if PVC is recorded earlier in the V1 lead, its source in 95.8% of the patients is RVOT and if PVC preceded the V2 lead, 70.59% of the patients had PVC from LVOT. Comparing of QRS onset in V1 and V2 leadsrecorded from third% and and second intercostal spaces had considerable sensitivity and specificity to determine the origin of the outflow tract PVC (81.82 and 94.12%, respectively)., Conclusion: Simultaneous recording of outflow tract PVCs from second third and fourth intercostal spaces and comparing their onset can determine the left and right outflow tract PVCs with high sensitivity and specificity., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Context: Various techniques have been proposed for suturing following prosthetic aortic valve implantation, but each has its potential side effects such as patient-prosthesis mismatch (PPM) and paravalvular leak (PVL)., Aims: In the present study, we aimed to compare the postoperative sequels of aortic valve replacement (AVR) following the use of two suturing techniques including from the inside of the aorta as the common and classic suturing techniques as compared to new approach including from the outside of the aorta., Settings and Design: This cross-sectional study was performed on patients suffering from symptomatic severe aortic valve disease and candidates for AVR in one of three referral hospitals for cardiovascular disease patients in Shiraz from 2019-2021., Subjects and Methods: The patients underwent one of the two considered surgical techniques for AVR including traditional approach ( n = 60) or the tested approach (suturing from the outside of the aorta) ( n = 30)., Statistical Analysis Used: For statistical analysis, results were presented as mean ± standard deviation for quantitative variables and were summarized by frequency (percentage) for categorical variables., Results: PVL and PPM were revealed in none of the participants undergoing the tested approach, while the pointed complications were found in 41.7% and 25.0% of patients underwent traditional approach, respectively, indicating a significant difference. There was no evidence of abnormal dimensionless valve index (DVI) in the patients undergoing sutures from outside the aorta, whereas the rate of DVI abnormality in the patients undergoing traditional procedures was shown to be 18.3%. The mean aortic valve gradient was significantly higher in the group scheduling for the traditional surgical method., Conclusions: Applying new suturing method as suturing from the outside of the aorta, due to the selection of appropriate valve size, the risk for adverse consequences including PPM, PVL, or DVI can be significantly reduced., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Cardiovascular Echography.)

Introduction: Heart rhythm management devices save patients' lives. However, they may cause problems with the patient's perspective of their body image. Therefore, given the significance of the heart function and cardiac rehabilitation, this study was conducted to investigate and compare the effect of the cardiac rehabilitation program on adjustment and body image among patients who use heart rhythm management devices. Methods: This two-group clinical trial was conducted with 100 patients who used various heart rhythm management devices. The patients were randomly assigned into either the control group or intervention group (50 patients in each group) via four triad blocks. The intervention was 16 sessions of the cardiac rehabilitation program and 4 telephone follow-ups over twelve weeks. Data was gathered before the intervention and both eight and twelve weeks after the intervention using the psychosocial adjustment to illness scale and the body image and relationships scale. Findings: The majority of the patients were male and in the age range of 40-60 years. Before the intervention, no statistically significant differences were reported between the groups in terms of adjustment control = 68.13 ± 9.1, intervention = 67.13 ± 4.6) and body image (control = 93.14 ± 8.5, intervention = 91.16 ± 8.4) ( P >0.5). However, in the intervention group, with each of three devices (pacemaker, ICD, CRT), significant improvements were observed in all aspects of adjustment (16.7 ± 9.3, 25.3 ± 9.5, 20.6 ± 10.3) and body image (45.50 ± 9.80, 55.10 ± 8.80, 42.90 ± 6.10) over time respectively ( P <0.001). Conclusion: The effectiveness of the cardiac rehabilitation program in improving the body image was reported in this study. Therefore, the cardiac rehabilitation program can have a vital role in improving body image and adjustment among patients who use various cardiac rhythm management devices., (© 2022 Marshfield Clinic Health System.)

We report the case of a 49-year-old female patient who underwent percutaneous coronary intervention of the right coronary and posterior descending arteries complicated with guidewire-induced coronary artery perforation. We successfully managed and sealed this perforation through the embolization of balloon pieces into the target vessel. ( Level of Difficulty: Advanced. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Background: Clinical importance of aVR lead-related changes in predicting the prognosis of acute myocardial infarction remains uncertain. The present study aimed to assess the value of ST-segment changes in aVR lead and the outcome and sequels of the first episode of acute ST-segment elevation myocardial infarction., Methods: This prospective cohort study was conducted on patients suffering first episode of ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention. Information was collected through hospital-recorded files reading. The electrocardiogram (ECG) was taken from the patients upon entering the hospital and followed-up for 30 days to assess cardiovascular complications., Results: In patients with anterior STEMI, with the use of multivariate analysis, admission aVR ST elevation ≥1 mm was found to be a strong and independent predictor of major cardiovascular adverse events (MACE) within 30 days of discharging ( P value for trend .002). In patients with inferior (± RV) ST-segment elevation myocardial infarction (STEMI), with the use of multivariate analysis, admission aVR ST depression ≥1 mm was found to be a strong and independent predictor of MACE within 30 days of discharging ( P value for trend .01)., Conclusion: In patients with anterior STEMI, admission aVR STE ≥1 mm was found to be a strong and independent predictor of MACE within 30 days of discharging. On the other hand, in patients with inferior STEMI, aVR ST depression ≥1 mm was found to be a strong and independent predictor of MACE within 30 days of discharging., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2021 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: There is some evidence of the association between ST-segment elevation in the V4R chest lead and the likelihood of anterior wall myocardial infarction; however, the link of this phenomenon with the location and the severity of the coronary involvements in such patients remains uncertain. We aimed to investigate the ST-segment elevation in V4R leads in patients with anterior myocardial infarction and also its effect on prognosis as well as the detection and prediction of the location of arterial stenosis in coronary angiography., Methods: Data collection was performed by reviewing the hospital recorded files of 195 patients' suspicion of acute myocardial infarction who have been referred within 2 h of the onset of cardiac symptoms. The patients were then categorized into two groups with and without ST elevation in the V4R chest lead., Results: Comparing two groups showed a significantly higher rate of concurrent ST-segment elevation in V 1 lead in those with ST-segment elevation in V4R. Echocardiography on the day after anterior myocardial infarction showed LVEF <40% in 74% and 35.2% of patients with and without ST-segment elevation in V4R, respectively, indicating a significant difference. The lesions on proximal LAD were more common in the group with ST-segment elevation in V4R., Conclusion: Our study emphasized a high likelihood of ST-segment elevation in V4R lead concurrently with ST-elevation in V 1 lead. Also, the appearance of ST-segment elevation in V4R lead can be accompanied with a lower LVEF, myocardial infarct size, involvement of proximal part of LAD, and Wrap around LAD., (© 2021 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Context: One of the most common endocrine disorders in children is diabetes which is the leading cause of premature cardiovascular disease in adulthood., Aims: This study is aimed to investigate the extend of cardiac involvement in diabetic children by speckle tracking echocardiography (STE) in comparison to two-dimensional (2D) echocardiography and routine laboratory data., Settings and Design: A cross-sectional study conducted on patients under 18 years of age who deal with type one diabetes mellitus for more than 5 years., Subjects and Methods: To compare the STE results, we included the STE data of 25 normal age-matched children. All patients underwent laboratory analysis for lipid profile, blood sugar, and 2D echocardiography plus STE., Statistical Analysis Used: Two-sample independent t -test, Chi-square test, logistic regression test, Spearman's rank correlation coefficient, and the Pearson correlation coefficient., Results: From March 2018 to 2019, we included 53 patients, mean age 15.8 ± 0.39 years and 52.8% female, and 25 nondiabetic control in this study. STE revealed global longitudinal strain (LS) -18.4 versus - 24.2 for patient (44 valid cases) versus control group, respectively, with significant statistical difference. Diabetic patients had lower LS in all segments compared to the control group., Conclusions: STE has very high sensitivity to detect cardiac involvement far earlier than 2D echocardiography. None of the routine biomarkers or demographic features can predict cardiac involvement based on segmental abnormalities of STE. Active investigation to clear the remote impact of STE abnormalities and its practical role in childhood diabetes management is highly recommended., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Cardiovascular Echography.)

Background: Anabolic androgens have been reported to be associated with cardiovascular complications. One study revealed that increase in vascular stiffness in bodybuilders is associated with anabolic androgens and improvement in vascular function may occur following anabolic androgens discontinuation. The aim of this study was to investigate any possible relation between aortic elastic properties and anabolic androgens., Methods: Study population was divided into 3 groups: Group-1 [n = 35] consisted of bodybuilders who denied any current or previous use of anabolic androgens. Group-2 [n = 18] was bodybuilders with regular using of anabolic androgens for at least 2 year prior to the start of our study. Group-3 was 13 healthy age-matched sedentary men as a control group. Cardiac echocardiography was performed in the bodybuilders and controls and indexes of aortic function were calculated., Results: Aortic stiffness was approximately twofold higher in anabolic androgens user bodybuilders compared with drug-free bodybuilders [P < 0.001]., Conclusion: The present study demonstrates that chronic anabolic androgens use clearly produces significant decrease in the elastic properties of aorta.

Background: Early repolarization (ER) pattern is diagnosed when the J-point is elevated on the patient's electrocardiogram. The aim of this study was to evaluate signal-averaged electrocardiography (SAECG) in patients with ER pattern., Methods: Subjects were divided into three groups: 1-patients with normal ECG pattern (control group); 2-patients with J-point elevation in the inferior leads; and 3-patients with J-point elevation in non-inferior leads., Results: The mean filtered QRS duration in groups with J-point elevation in inferior leads and non-inferior leads and in the control, was 86.4 ± 23.4 msec, 84.8 ± 26.6 msec, and 85.8 ± 24.8 msec, respectively, indicating no significant difference across the three groups. The mean duration of terminal QRS < 40µV was 21.2 ± 4.2 msec, 22.8 ± 4.6 msec, and 23.1 ± 4.5 msec in the mentioned groups, respectively, without a significant difference between the groups. Additionally, the mean root-mean-square voltage of terminal 40 msec was 34.5 ± 8.3 µV, 35.3 ± 8.6µV, and 35.7 ± 9.2 µV in patients with increased J-point in inferior leads, non-inferior leads, and the control group, respectively, showing no difference between the groups., Conclusion: In conclusion, we found that parameters in SAECG did not have any significant difference between patients with ER pattern and healthy individuals. Moreover, we concluded that SAECG cannot distinguish the patients with elevated J-point in inferior leads from non-inferior leads. Overall, SAECG does not appear to be a reliable diagnostic tool for the assessment of ER pattern., Competing Interests: None., (© 2021 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.)

Introduction: Gradual painful loss of active and passive range of motion in shoulder joint was introduced as adhesive capsulitis (AC). Disabilities in patients with AC are absenteeism from work, loss to leisure time, and recurrent seeking to health care services. The aim of this study was to evaluate the incidence of AC following pacemaker implementation. The effect of physical therapy and exercise education was also evaluated to prevent AC following pacemaker implementation., Methods: This study is a randomized clinical controlled trial. It was conducted on 62 pacemaker candidates. Patients with no shoulder pain and without any motion limits were enrolled in the study consecutively. The patients randomly were divided into two groups after pacemaker implementation. One group was treated with physical therapy (group A, n = 28) and the other group did not (group B, n = 34). The incidence of AC was assessed in both groups after 4 months., Results: A total of 62 patients were enrolled in the study. The mean age was 63.2 ± 12.1 years in the group A and 67.1 ± 17.6 years in the group B. Age was not significantly different between groups. A total of 11 patients (17.7%) had AC 16 weeks after the initial visit (two patients in group A and nine patients in group B; P = .004)., Conclusions: Incidence of AC is 17.7% following device implantation. Exercise education and physical therapy significantly reduces AC incidence following pacemaker implantation., (© 2020 Wiley Periodicals LLC.)

Background: Dietary fish is a rich source of Omega-3 poly-unsaturated fatty acids (PUFAs). These compounds may have protective effect against cardiovascular events possibly by modifying lipid profiles. Consequently, fish oil supplements are produced commercially to complement low fish intake. It is not clear if both interventions have similar effects. The aim of this trial was to compare the anti-hyperlipidemic effect of omega3 fatty acid supplements with fresh fish., Method: A total of 106 patients with hyperlipidemia were randomized. One group received 2 g/day of omega-3 capsules for a period of 8 weeks and the other group received a mean of 250 g trout fish twice weekly (for dinner and lunch) for the same time period. The effects of these diets on the lipid profile after the intervention were compared between the two groups., Results: Data from 48 patients in fish oil group and 47 patients from fish group was used for final analysis. In both groups, total cholesterol, non-HDL cholesterol, triglyceride (TG) levels, and Castelli I index (total cholesterol/HDL ratio) were reduced significantly following the treatment; however, dietary-fish intake had a more pronounced effect (-85.08 ± 74.82 vs. -30.75 ± 89.00, P < 0.001; 75.06 ± 35.43 vs. -16.93 ± 40.21, P < 0.001; -66.55 ± 30.79 vs. -12.7 ± 35.48, P = 0.003; and -0.77 ± 1.39 vs. -3.02 ± 1.85, P < 0.001; respectively). HDL level was increased in both groups with a higher effect in dietary fish group (4.47 ± 7.83 vs. 8.51 ± 8.79, P = 0.022). Atherogenic (Log [TG/HDL ratio]) and Castelli II (LDL/HDL ratio) indices did not change in fish oil group while were reduced significantly by fresh fish consumption (-0.04 ± 0.27 vs. -0.26 ± 0.17, P < 0.001; and 0.15 ± 0.7 vs. -1.32 ± 1.15, P < 0.001, respectively). LDL level was increased in the supplementation group, while it was significantly reduced in the dietary-fish group (+18.7 ± 24.97 vs. -22.75 ± 27.28, P < 0.001)., Conclusion: Consumption of fresh fish seems to be superior in positively modifying the lipid profiles which may have important translations in the occurrence of cardiovascular events.

Background: Cardiac resynchronisation therapy (CRT) is an accepted device therapy in patients with low ejection fraction. Beneficial effects of CRT result from mechanical remodelling. Some controversial reports suggest that CRT may also induce electrical remodelling with intrinsic QRS narrowing but still the effect of CRT on electrical remodelling is an issue for debate. The aim of our study was to evaluate the effects of CRT on intrinsic QRS duration. For clarity, our analysis was performed by the signal averaged electrocardiogram (SAECG) which is a high resolution electrocardiographic signal suitable for accurate measurement of QRS duration. Signal averaged electrocardiogram provides a better value of QRS duration compared to 12-lead ECG by the ability to detect ventricular late potentials., Methods: A total of 48 consecutive patients with severe systolic dysfunction and typical left bundle branch block (LBBB) were enrolled in the study prospectively. Patients were scheduled for CRT-D implantation according to the current guidelines. Intrinsic QRS duration was accurately measured by SAECG before and at least 14 months after CRT implantation., Results: The mean intrinsic QRS duration remained unchanged during follow-up (from 149.9±13.8ms to 149.6±18.4ms; P= 0.3). Among 32 CRT responder patients, the mean intrinsic QRS duration remained unchanged during follow-up. Also, the mean intrinsic QRS duration showed no significant changes in 16 CRT non-responders., Conclusion: Structural remodelling induced by CRT does not necessarily translate into decrease of intrinsic ventricular activation. Despite significant left ventricular recovery, electrical characteristics of the left ventricular conduction system cannot generally be expected to recuperate., (Copyright © 2015. Published by Elsevier B.V.)

Background: There are only limited prospective data on the clinical relevance of current of injury (COI) as a predictor of the midterm performance of active-fixation leads. This study sought to investigate whether it is possible to predict the midterm performance of active-fixation leads using COI recorded at the time of implantation., Methods and Results: One hundred fifty patients (78 men; mean age, 63 ± 19 years) who received active-fixation pacing (n = 201) and defibrillator (n = 51) leads were studied. COI was measured from the intracardiac bipolar electrogram recorded at the time of lead implantation. The study outcome was good lead performance at 6 months, defined as P wave ≥ 1.5 mV, threshold <1.5 V for atrial lead, R-wave ≥ 5 mV, and threshold <1 V for ventricular lead. A total of 102 active-fixation atrial and 150 ventricular leads were implanted. During a 6-month follow-up, invasive intervention was required for seven atrial and seven ventricular leads. In multivariate analysis, COI was the only independent predictor of good outcome for the active-fixation atrial (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 2.18-14.76, P = 0.001) and ventricular leads (OR: 3.99, 95% CI: 1.08-21.26, P = 0.002). Receiver-operating characteristic analysis identified ST-segment elevation ≥2.0 mV for the atrial leads (sensitivity, 75%; specificity, 89%) and ≥10.0 mV for the ventricular leads (sensitivity, 70%; specificity, 87%) as optimal cutoffs for good midterm performance., Conclusions: Midterm performance of active-fixation leads is predictable using COI recorded at the time of lead implantation. A ST-segment elevation ≥2.0 mV in the atrial leads and ≥10.0 mV in the ventricular leads are recommended to improve the lead performance at 6 months., (©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.)

Introduction: High sensitive C-Reactive Protein (hs-CRP) is increased in acute and chronic rheumatic fever (RF), but is unknown whether serum levels of hs-CRP is correlated with late restenosis of mitral valve (MV) after Percutaneous transvenous mitral commissurotomy (PTMC). The aim of this study is to determine relationship between hs-CRP and MV restenosis 48-36 months after performing PTMC., Methods: A total of 50 patients who had undergone PTMC due to rheumatic etiology (41 female, 9 male; mean age 46 ± 11, range 27-71), all followed up on an out patients basis 36 months after PTMC, were included in the study. The hs-CRP was measured using an enzyme-linked immunosorbent assay (ELISA) kits., Results: No association was found between hs-CRP level and mean transmitral valve gradient 36 months after PTMC, MV area by planimetry, pulmonary artery systolic pressure, mitral regurgitation grade, left atrial diameter, atrial fibrillation (AF) rhythm and Wilkins score., Conclusion: Our study have shown that there is no association between hs-CRP and MV restenosis in patients with rheumatic heart disease (RHD) who underwent PTMC. Therefore, it has been postulated that inflammation is not a cause of post PTMC restenosis.

Prosthetic tricuspid valve is an obstacle to implant cardiac devise. Cardiac Resynchronization therapy is one of the most popular therapies for heart failure patients these days. We present this case of prosthetic tricuspid valve and left ventricular dysfunction which we overcome the problem by implanting two leads to coronary sinus branches. Patient improved in few months of follow up.

Background: Obstetricians regard maternal age of 20 to 35 years as the optimal age for pregnancy. Adolescent pregnancy and pregnancy at the ages of 35 years and above are associated with higher risks. Pregnancy is pro-arrhythmic and rarely precipitates ventricular arrhythmias., Objectives: QT dispersion is an index of heterogeneity of ventricular repolarization and a predictor of propensity of ventricular arrhythmias. In this study, this index was used to find any relationship between maternal age and ventricular arrhythmia risk., Methods: This study was performed among a group of healthy pregnant ladies between 36 and 40 weeks of gestation. An ECG was taken from each patient. QT dispersions were calculated on a computer screen with high magnitude. The results were then divided into three groups based on the age of the participants. The first, second, and third groups included the women below 20, between 20 and 35, and over 35 years, respectively. The three groups were compared using Kruskal-Wallis test., Results: The mean QTd was 61.77 ms (± 16.61) in the first group, 64.15 ms (± 18.65) in the second group, and 55.95 ms (± 23.04) in the third group. Although QTd was prolonged in all, no significant difference was observed among the three groups regarding QTd., Conclusions: Our results showed QT prolongation in pregnancy, but showed that maternal age did not affect the heterogeneity of ventricular repolarization and propensity of ventricular arrhythmias in pregnancy.

Background: The Brugada syndrome is a heterogeneous genetic disease that predisposes to life-threatening ventricular tachyarrhythmias and sudden cardiac death (SCD). The only proven way to prolong the survival of patients with Brugada syndrome is to implant an implantable cardioverter-defibrillator (ICD). This should be implanted for high-risk patients only., Method: The patients with type 2 or 3 Brugada ECG pattern were selected for the study. We evaluated 126 patients with Brugada type ECG patterns. Nineteen patients had positive response. Those who had positive result in right side located leads had poorer prognosis., Conclusion: Positive flecainide challenge test in right side located pericordial leads can be used as a predictor of poor prognosis in Brugada patients. This can be evaluated in another research for its role in the implantation of ICD. Also, the oral flecainide is not sensitive enough to rule out the presence of Brugada syndrome and it should not be trusted as a screening test for suspected cases., (©2013 Wiley Periodicals, Inc.)

Background/objectives: Sodium channel blockers are used to unmask the diagnostic ECG pattern of the Brugada syndrome (BrS) in case of a non-diagnostic baseline ECG. The aim of the study was to determine clinical and ECG predictors of a positive challenge test in patients suspected to the BrS., Methods: A total of 106 consecutive patients (91 men; mean age, 35 ± 12 years) suspected of the BrS underwent the intravenous sodium channel blocker challenge test with procainamide or flecainide., Results: Of the 106 patients, positive tests were detected in 20 (19%) patients. During test, a transient episode of a second-degree atrioventricular block and isolated ventricular ectopies were observed in 1 (0.9%) and 2 (1.9%) patients, respectively. A QRS prolongation ≥ 30% was observed in 4 (3.8%) patients. Baseline QRS duration in V1 ≥ 110 ms had a sensitivity of 70% and a specificity of 80% for a positive response. An ST-segment elevation ≥ 0.17 mV in V2 had a sensitivity of 60% and a specificity of 82% for a positive response. Of the multiple clinical and ECG variables entered into a binary logistic regression analysis, a history of syncope (P=0.001), previous cardiac arrest (P=0.001), baseline QRS duration in V1 ≥ 110 ms (P=0.001), and baseline ST-segment elevation in V2 ≥ 0.17 mV (P=0.012) emerged as the independent predictors of a positive response to the intravenous challenge with sodium channel blockers., Conclusion: The results of the sodium channel blocker challenge test can be predicted by clinical presentation and baseline ECG features., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A 37-year-old man, known case of mitral valve replacement, was referred for ablation. Meticulous mapping showed the earliest signal in the distal coronary sinus (CS). Endocardial ablation via transseptal approach failed to permanently ablate the accessory pathway. Similarly, ablation within the CS was unsuccessful. Finally, the mapping catheter was introduced into the vein of Marshall (VoM) and a very early signal was obtained. In the first 3 seconds of the radiofrequency energy application within the VoM, delta wave disappeared. During 1-year follow-up, the patient had no recurrence of the palpitations and electrocardiogram showed no delta wave., (©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc.)

Background: Diabetes mellitus is a life threatening disease accompanied by several micro- and macro vascular complications. Several modalities are available for interventional revascularization of coronary artery lesions, but their efficacy in diabetic patients is studied only in few patients., Materials and Method: This study evaluated major in- hospital complications and clinical outcome after one year in 200 consecutive patients who underwent percutaneous Coronary Intervention from 2007 to 2009., Results: Our findings showed comparable single and 2 vessel stenting, regarding major adverse cardiovascular event in diabetic and nondiabetic patients. In connection with long term and in hospital outcome, no statistically significant difference was found between one and two vessel stenting when drug eluting stent was used in diabetic patients., Conclusion: The use of drug eluting stent in single or two vessel disease of diabetic patients is technically satisfactory and clinically safe and can substitute for coronary artery bypass grafting.

Background: In patients with low ejection fraction and ventricular dyssynchrony, cardiac resynchronization therapy (CRT) is an accepted therapeutic modality. In these patients, CRT can improve the quality of life and exercise tolerance in addition to improved survival. On the other hand, antiarrhythmic effects of CRT is a place of debate., Method: In this study, we evaluated the effect of CRT-induced reverse remodeling on ventricular arrhythmia in heart failure patients. Patients with CRT were divided to two groups of responders and nonresponders. Responders were those with reduction of LVESD of more than 10% or increase in LVEF of more than 5%. They were visited and device analysis was performed during the follow-up., Results: One hundred and nineteen patients were enrolled in this study. Those with reverse remodeling experienced fewer ventricular arrhythmias after two years of follow-up (N = 2 vs 11, P = 0.001)., Conclusion: Reverse remodeling associated with CRT implantation can result in decreased frequency of ventricular arrhythmias., (©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.)

Objectives: The aim of this study was to investigate the effects of 8-week endurance and resistance exercise training on release of brain natriuretic peptide., Materials and Methods: Study population was categorized into 4 groups: Group-1 (n = 6) consisted of sedentary individuals who volunteered to complete 8-weeks of endurance exercise; Group-2 (n=6) consisted of sedentary individuals who volunteered to complete 8-weaks of resistance exercise. Three blood samples [for Terminal pro BNP (NT-Pro-BNP)] were taken before, immediately after exercise and after 8 weeks of exercise training., Results: NT-Pro BNP was significantly increased immediately after endurance exercise [from 37.9 ± 1.4 pg/ml to 52.1 ±1.5 pg/ml; P = 0.002] and was decreased to 23.2 ± 9.3 pg/ml after 8 weeks of endurance exercise [P = 0.013]. On the other hand, NT-Pro BNP showed no significant changes immediately after resistance exercise [from 26.6 ± 4.9 pg/ml to 24.1 ±4.5 pg/ml; P = 0.553]. In contrast, NT-Pro BNP was significantly increased to 39.5 ±1.6 pg/ml after 8 weeks of resistance exercise [P = 0.012]., Conclusion: Endurance exercise training reduces circulating NT-Pro BNP concentration, which is likely a marker of reduced ventricular wall tension and improved myocardial function. In contrast, strength exercise induces significant increase in NT-Pro BNP, which could be partially attributed to myocardial damage.

Objectives: It is known that exercise induces cardio-respiratory autonomic modulation. The aim of this study was to assess the cardio-pulmonary fitness by ultra-short heart rate variability., Materials and Methods: Study population was divided into 3 groups: Group-1 (n = 40) consisted of military sports man. Group-2 (n = 40) were healthy age-matched sedentary male subjects with normal body mass index [BMI = 19 - 25 kg/m(2)). Group-3 (n = 40) were healthy age-matched obese male subjects [BMI > 29 kg/m(2)). Standard deviation of normal-to-normal QRS intervals (SDNN) was recorded over 15 minutes. Bruce protocol treadmill test was used; and, maximum oxygen consumption (VO(2)max) was calculated., Results: WHEN THE STUDY POPULATION WAS DIVIDED INTO QUARTILES OF SDNN (FIRST QUARTILE: < 60 msec; second quartile: > 60 and < 100 msec; third quartile: > 100 and <140 msec; and fourth quartile: >140 msec), progressive increase was found in VO(2)max; and, SDNN was significantly linked with estimated VO(2)max., Conclusion: In conclusion, the results of this study demonstrate that exercise training improves cardio-respiratory autonomic function (and increases heart rate variability). Improvement in cardio-respiratory autonomic function seems to translate into a lower rate of long term mortality. Ultra-short heart rate variability is a simple cardio-pulmonary fitness test which just requires 15 minutes, and involves no exercise such as in the treadmill or cycle test.

We report an example of the negative current of injury (COI) during permanent pacemaker implantation. Cardiac perforation was our first priority. However, patient had stable hemodynamics, and the fluoroscopic location of the atrial lead was acceptable. Therefore, the connections were checked revealing the cause of the negative COI; the red (+) clips was attached to the tip of the atrial lead rather than anodal ring. Correcting the connections resolved the problem. This report shows that a negative COI might not only be due to cardiac perforation or right ventricular ischemia but that checking the lead connectivity should be carried out first., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: #ENTITYSTARTX02014; The Yellow Oleander is an ornamental tree that is common throughout the tropics. Ingestion of its seeds results in a clinical picture similar to digoxin toxicity., Objectives: #ENTITYSTARTX02014; The aim of this study was to evaluate cardiac findings in acute Yellow Oleander poisoning., Methods and Materials: #ENTITYSTARTX02014; A total of 21 patients with history of Yellow Oleander ingestion were enrolled in this study., Results: #ENTITYSTARTX02014; All symptomatic patients had conduction defects affecting the sinus node, theatrio-ventricular node or both. Patients showing cardiac arrhythmias that required specific management had significantly higher serum potassium concentrations., Conclusion: #ENTITYSTARTX02014; Most of the symptomatic patients had conduction defects affecting sinus or atrio-ventricular nodes but few had atrial or ventricular arrhythmias typical of digoxin poisoning.

Background: Response of the human heart to exercise has been studied extensively, but little information is available on the effects of exhaustive exercise on cardiac performance., Objectives: The aim of this study was to evaluate the effect of severe prolong exercise on both left and right ventricular performance. To maximize the sensitivity of our study we used tissue Doppler imaging., Methods: Participants in army ranger training program were invited to participate in this prospective study. All patients underwent transthoracic echocardiography using tissue Doppler imaging before and after Ranger training program., Results: A total of 45 consecutive male rangers who completed 8 weeks of training were included in this study. Peak systolic myocardial velocity (S) decreased significantly after training (12.46 +/- 0.54 vs. 9.93 +/- 0.45 cm/s; P < 0.001). In the right ventricle, tissue Doppler measures of systolic and early diastolic function decreased significantly after training compared to pretraining values., Conclusion: In conclusion, very strenuous prolonged exercise may result in depressed left ventricular contractile function. This raises the possibility of cardiac fatigue.

A 22-year-old man with a 4 month history of dyspnoea on exertion was referred for echocardiography. Transthoracic echocardiography revealed a balloon-shaped cystic mass (2 x 2 cm) attached to the left ventricular outflow tract (LVOT). Continuous-wave Doppler echocardiography showed a 44 mmHg mean LVOT gradient. The patient underwent transoesophageal echocardiography for detailed echocardiographic examination of LVOT and aortic valve. Transoesophageal echocardiography revealed a balloon-shaped cystic mass originating from the LVOT at the aorto-mitral communication. In the operating theatre, a cystic ballooning subaortic membrane was found and excised successfully. The morphology of the membrane was similar to that shown by transoesophageal echocardiography.

A 26-year-old man presented to emergency department with fever associated with night sweating and weight loss since 2 months prior to admission. He was an intravenous heroin user admitted for infective endocarditis of aortic valve 1 year ago. Transthoracic echocardiography followed by the transesophageal study showed bileaflet aortic prosthesis with normal transvalvular gradient and severe paravalvular aortic insufficiency. A pseudoaneurysm of intervalvular fibrosa connecting left ventricular outflow tract (LVOT) to noncoronary sinus of valsalva was detected.

Objectives: To find the relationship between anabolic androgenic steroids (AAS) using and QT interval in athletes., Methods: Between January 1, 2005 and May 31, 2007, we examined QTc interval duration in 165 consecutive male professional bodybuilders [age: 32.1 +/- 4.6 years]. Of these, 79 were AAS users. The control group included 90 sedentary age and gender matched subjects [none of them were AAS users]., Results: The QTc interval of AAS abusing bodybuilders was significantly shorter compared with QTc interval in AAS-free bodybuilders and control group. Short QTc interval (< or =380 ms) was an independent predictor of AAS abusing in the multivariate analysis., Conclusions: To the best of our knowledge, there is no published report regarding electrocardiographic diagnosis and screening of AAS abusing athletes. In the present study, we present an easy and applicable method to screen and diagnose AAS abusing among professional bodybuilders. In the presence of QTc interval < or = 380 ms in a bodybuilder, one would predict AAS abusing with 83% sensitivity and 88% specificity.

Aims: Risk stratification in Brugada syndrome (BS) is controversial especially in asymptomatic individuals. The aim of this study was to evaluate the significance of cardiac autonomic neuropathy (CAN) in BS., Methods and Results: Patients diagnosed with Brugada ECG pattern were enrolled in the study. Four standard cardiac autonomic function tests were performed. The presence of >or=2 abnormal test results were considered definite evidence for the presence of CAN. Types 1, 2, and 3 Brugada ECG pattern were found in 28, 56, and 31 patients, respectively. CAN was detected in 13 (46%) patients with type 1 Brugada ECG pattern. In contrast, none of the type 2 or 3 Brugada patients had CAN. Of 13 patients with CAN, 11 had previous history of cardiac events (84%), whereas only 2 of 15 patients without CAN had history of previous cardiac events (13%; P = 0.01). The most noteworthy finding was that all of the type 1 Brugada patients with CAN were male (CAN was not detected in females)., Conclusions: It was concluded that CAN is an important risk indicator in BS. CAN is more common in men. Male gender, per se, is not an independent risk factor for development of ventricular arrhythmia but also CAN, which is an important risk factor in BS, is more common in men; therefore men are susceptible to the development of cardiac events.

In the present study we describe two similar severe cases of Löffler's endocarditis in which eosinophilic infiltrations obliterated the entire right ventricular cavity and caused severe right ventricular dysfunction.

Differentiating coronary artery disease with left ventricular dysfunction from dilated cardiomyopathy is important prognostically and therapeutically. To provide a diagnostic algorithm to distinguish these conditions using a standard 12-lead electrocardiogram, all 105 patients with left ventricular ejection fraction < 50% who underwent angiography between January 2004 and December 2006 were studied prospectively. Coronary artery disease was defined as >/= 50% stenosis of the left main coronary artery or >/= 70% stenosis of 1 or more of the 3 major epicardial arteries. Normal coronary angiography findings with left ventricular ejection fraction < 50% was defined as dilated cardiomyopathy. The most specific finding for differentiation of these diseases was pathologic Q waves in lead II, aVF, V3 or V4. The most sensitive parameter was a ratio >/= 5 of R-wave amplitudes in lead V6 and lead III (94% sensitive). The 12-lead electrocardiogram provides a useful noninvasive method for differentiation of dilated cardiomyopathy from coronary artery disease with left ventricular systolic dysfunction.

A 51-year-old woman with severe rheumatic mitral stenosis underwent mitral valve replacement. One week later, she was admitted with abdominal pain and lower extremities edema. On physical examination, her blood pressure was 120/60 mm Hg and holosystolic murmur (3/6) was heard at the left sternal border. Transesophageal echocardiography was done and revealed a shunt flow from the left ventricle to the right atrium in the 4-chamber and bicaval views. With careful examination of the interventricular septum, a small defect was seen in the membranous interventricular septum, which connects the left ventricle to the right atrium. The patient underwent surgical operation with diagnosis of iatrogenic left ventricular to right atrial communication (Gerbode-type defect). Intraoperative finding confirmed the preoperative diagnosis.

A previously well 45-year-old male presented with 20 days of being generally unwell with a fever and dyspnoea on exertion. Transthoracic echocardiography was done and revealed a round cystic structure (3 x 3 cm) attached to the tricuspid valve. Multiple small calcified particles (daughter cysts) were also seen in the cyst which was most consistent with the diagnosis of Hydatid cyst. The serology for Echinococcus granulosus antibody was positive and confirmed the diagnosis. The patient was sent for cardiac surgery and hydatid cyst which was endocardial in location, and adherent to the tricuspid valve leaflets was the intraoperative finding. The patient improved and was discharged on long-term chemotherapy. The most common cite of cardiac involvement is the myocardium followed by the pericardium, whereas endocardial involvement is extremely rare. In the present study, we demonstrated a very rare case of endocardial hydatid cyst with attachment to the tricuspid valve.

Background: Any unfavorable effect of cocaine on aortic elastic properties will contribute to the adverse effects of cocaine on the cardiovascular system., Objectives: The aim of this study was to evaluate the aortic elastic properties in long-term crack cocaine abusers., Methods: Twenty-eight consecutive chronic cocaine abusers and 36 control subjects with similar age, gender, cholesterol, and triglyceride plasma levels, as well as incidence of cigarette smoking, hypertension, and diabetes mellitus were enrolled in the study., Results: The average duration of cocaine abuse was 10 +/- 3.2 years. Diastolic thoracic aortic diameter was increased in cocaine users compared with control subjects (P < 0.05). Aortic strain and distensibility were approximately twofold lower and aortic stiffness index approximately threefold higher in patients compared with control subjects (P < 0.01). The duration of cocaine abuse was related to low aortic strain and distensibility as well as increased aortic stiffness index (R =-0.32, R =-0.38, and R = 0.28, respectively, weighted for age; P < 0.01). When the cocaine abusers were divided into quartiles of duration of cocaine using (first quartile: <5 years; second quartile: >5 and <8 years; third quartile: >8 and <11 years; and fourth quartile: >11 years), progressive increase was found in aortic stiffness index., Conclusion: The present study demonstrates that chronic cocaine abuse clearly produces significant decrease in the elastic properties of aorta. This effect of cocaine is related to the duration of cocaine abuse.

Background: Risk stratification in Brugada syndrome is controversial, especially in asymptomatic individuals., Objective: The purpose of this study was to evaluate tissue Doppler echocardiography in risk stratification of Brugada syndrome., Methods: Patients with Brugada ECG pattern were enrolled in the study. Left ventricular (LV) preejection period was defined as the time interval between onset of the QRS complex and onset of LV lateral wall systolic wave. Right ventricular (RV) preejection period was defined as the time interval between onset of the QRS complex and onset of RV lateral wall systolic wave. Delay in onset of contraction between RV and LV was defined as RV preejection time - LV preejection time [PET((RV-LV))]., Results: Type 1, 2, and 3 Brugada ECG pattern was found in 30, 56, and 31 patients, respectively. PET((RV-LV)) was significantly greater in type 1 Brugada patients (39.2 +/- 3.2 ms) compared with type 2 (5 +/- 0.3 ms) and 3 (5 +/- 0.4 ms) Brugada patients as well as controls (4.6 +/- 0.3 ms, P <.01 for all comparisons). Among type 1 Brugada patients, PET((RV-LV)) was significantly greater in patients who had previous cardiac events compared with asymptomatic subjects (48.2 +/- 4.3 ms vs 29.5 +/- 3.6 ms, P <.05). In the presence of type 1 Brugada ECG pattern, PET((RV-LV)) > or =40 ms identifies patients likely to have cardiac events, with 85.7% sensitivity and 93.7% specificity., Conclusion: PET((RV-LV)) is an important risk indicator for Brugada syndrome.

A 50-year-old man presented with chest pain and recurrent episodes of syncope. Physical examination revealed a loud systolic murmur at the left sternal border with accentuation in erect position. Transthoracic echocardiography demonstrated severe asymmetrical septal hypertrophy and systolic anterior motion of the anterior mitral valve leaflet which were diagnostic for hypertrophic cardiomyopathy. Interestingly, color Doppler examination of the left ventricle showed aliasing of the left anterior descending coronary artery and intra-myocardial coronaries.

A 65-year-old man, heavy smoker, was admitted because of severe exertional dyspnea and vague chest pain for 2 weeks. A chest X-ray was taken and revealed a large mass in the left lung field (Figure 1). Cytological examination of the percutaneous needle aspiration of a lymph node in the anterior mediastinum revealed malignant epithelial cell nests which was strongly suggestive of squamous cell carcinoma. Transthoracic echocardiography was performed and revealed multiple mass-like lesions with central liquefactions in the left ventricle resembling a bunch of grapes.

Background: We screened a large number of liver transplant candidates with contrast echocardiography to detect intrapulmonary right to left shunt (IPS). We found that IPS is frequently present in patients with left atrial enlargement. This finding raises a question concerning the correlation between IPS and left atrial size in patients with liver cirrhosis., Objectives: The aim of this prospective study was to evaluate the possible correlation between left atrial size and IPS in patients with liver cirrhosis., Methods: Adult patients (>18 years old) with documented liver cirrhosis underwent trans-thoracic contrast echocardiography with agitated saline. Left atrial dimension was measured by M-mode echocardiography. Stroke volume was calculated using left ventricular M-mode echocardiography. Patients with atrial fibrillation, intracardiac shunt, congenital heart defects, valvular heart disease and diastolic dysfunction were excluded., Results: A total of 92 patients met all study criteria. Of these, 39 (42.3%) had IPS. Cardiac output was significantly greater in patients with IPS compared with those without IPS (5.68 +/- 0.83 L/min vs 4.75 +/- 0.76 L/min, P < 0.01). In a multi-variable model, after adjustment for body surface area and body mass index, left atrial enlargement was the strong predictor of IPS (area under the curve = 0.66) but when controlling for cardiac output, left atrial size was not an independent predictor of IPS., Conclusion: In the context of liver cirrhosis, patients with IPS have greater cardiac output compared with those without shunt. Left atrial enlargement, which reflects one aspect of increased cardiac output, is an indirect marker of IPS and greater left atrial dimension is associated with the presence of intrapulmonary right-to-left shunt.

Flash pulmonary edema is a condition characterized by sudden and recurrent episodes of dyspnea resulting from acute pulmonary venous congestion in the presence of normal or well-preserved left ventricular systolic function. This is usually associated with bilateral renal artery stenosis or stenosis of a single surviving kidney. We describe a patient with clinical presentation of flash pulmonary edema due to renal artery spasm. To the best of our knowledge, this is the first reported case of flash pulmonary edema due to renal artery spasm., ((c) 2007 S. Karger AG, Basel)