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A 38-year-old man presented with an acute anterior myocardial infarction (MI) and was subjected to thrombolysis. Echocardiography and cardiac catheterization revealed a mass in the left atrium that was considered to be a myxoma. The coronary arteries appeared normal on angiography. The left atrial mass was removed surgically without complication. Histopathologic examination confirmed the diagnosis of the myxoma. Coronary embolism secondary to the myxoma was thought to be the cause of the MI.

Objective: Coronary artery ectasia (CAE) is the abnormal dilatation of a segment of the coronary artery to a diameter of at least 1.5 times that of normal adjacent segments. Symptoms are variable, and its prognosis and treatment modalities are unclear. The aim of this study is to evaluate the effect of trimetazidine (TMZ) on ischemic left ventricular function by rest-stress Tc-99m methoxyisobutyl isonitrile (Tc-99m MIBI) myocardial scintigraphy in symptomatic patients with CAE., Methods: We included patients with ectasia admitted to our Cardiology Department, Turkey, between 2003 and 2004 in this study. All patients underwent coronary angiography and diagnosed with CAE, before and 4 weeks after TMZ administration. Seventeen patients (9 men, 8 women) underwent gated single-proton emission tomographic (SPECT) using Tc-99m MIBI. We performed quantitative global and regional ventricular functional analysis using quantitative gated SPECT software., Results: The global ejection fraction increased from 59.9%+/-8.9% to 62.6%+/-8.3% after therapy (p=0.033). In addition, the end systolic volume and the end diastolic volume decreased after therapy (101.7+/-23.5 ml to 95.1+/-22.9 ml, p=0.002; from 41.1+/-14.3 to 36.4+/-13.6, p=002). In all segments, we observed significant post-therapy increases in relative tracer uptake. Percentage of MIBI uptake was 71.2+/-15.3 at baseline stress and 73.2+/-15 post-TMZ (p=0.001). As global function parameters, the total wall motion normal areas changed significantly (67-74% p=0.01) after therapy, but the total wall thickness did not changed significantly(49-45%, p=0.21)., Conclusion: The results of this study demonstrate that TMZ improves myocardial function by rest-stress Tc-99m MIBI gated SPECT during stress-induced ischemia in patients with CAE. Also, the outcomes revealed improvement in functional parameters, and percentage of MIBI uptake post TMZ administration. We can use this procedure to monitor the effect of TMZ in CAE patients.

Background: Behçet's disease is a systemic vasculitis in which studies have given conflicting results about ventricular diastolic functions. However, tissue Doppler echocardiography has never been used in any of these studies. Aortic stiffness, a cardiovascular risk factor, may also precede ventricular dysfunction., Objectives: The aim of this study was to assess aortic stiffness and biventricular diastolic functions in patients with Behçet's disease., Methods: A total of 26 patients with Behçet's disease (mean age; 33+/-10 years) and 20 age- and sex-matched controls (mean age; 33+/-7 years) were included. Aortic stiffness was evaluated by aortic strain and distensibility. Ventricular diastolic functions were evaluated with both conventional and tissue Doppler echocardiography. Mitral E and A wave, E/A ratio of E wave, deceleration time, and isovolumic relaxation time were calculated., Results: There was no significant difference in diastolic Doppler parameters between patients and controls. Similarly, there was no significant difference in mitral annular E and A velocities between these two groups. Aortic strain in patients with Behçet's disease was found to be significantly less than in the controls (8.3+/-4.9% and 15.7+/-2.7% respectively, p<0.001). Aortic distensibility was also significantly low in patients with Behçet's disease when compared to controls (0.45+/-0.28 and 0.78+/-0.13 respectively, p<0.001). Beta index values were significantly high in Behçet's patients (7.23+/-5.93 and 2.69+/-0.55 respectively, p<0.001)., Conclusion: No significant diastolic dysfunction was found in left and right ventricles in patients with Behçet's disease by using both conventional and tissue Doppler echocardiography. However, an increase in aortic stiffness was found, suggesting an inflammatory involvement of proximal aorta.

Background: Current reperfusion strategies may fail to achieve optimal tissue perfusion in ST-elevation myocardial infarction (STEMI). We investigated the effect of clopidogrel plus aspirin on tissue perfusion and coronary flow in infarct patients treated with fibrinolytic agents., Methods: Consecutive 78 patients with STEMI were randomized to receive clopidogrel plus aspirin (clopidogrel group, n = 42) or placebo plus aspirin (placebo group, n = 36) before streptokinase. Maximum and total ST-segment resolutions (sumSTR) were calculated at 90 minutes after fibrinolysis. TIMI flow grade and corrected TIMI frame count in infarct-related artery were evaluated at predischarge. Inhospital ischemic and hemorrhagic events were also analyzed., Results: Baseline characteristics were comparable in both groups. Both mean maximum ST-segment resolution (54.5 +/- 21.3% vs 44.6 +/- 22.0%, P = .047 ) and sumSTR (52.7 +/- 21.1% vs 42.8 +/- 20.7%, P = .041) were slightly higher in the clopidogrel group than placebo group. The rate of complete sumSTR 70% was significantly higher in the clopidogrel group compared with placebo group (31% vs 11%, P = .021). TIMI flows were similar in both groups, but corrected TIMI frame count was significantly lower in the clopidogrel group compared with placebo group (25.5 +/- 10.5 vs 33.5 +/- 11.8 frames, P = .027). Clinical events were comparable in 2 groups; however, there were 1 death caused by heart failure and moderate bleeding in the clopidogrel group., Conclusion: Our results suggest that clopidogrel plus aspirin compared with aspirin alone may improve myocardial tissue perfusion and coronary flow in STEMI patients receiving streptokinase.

Objective: The aim of this study was to evaluate the QT intervals at different rest heart rates in healthy middle-aged Turkish men and to compare the known four QT adjusting methods for heart rate., Methods and Results: The QT intervals were measured in electrocardiograms of 210 healthy men (mean age = 35-60 years). A curve relating QT intervals and heart rates from 45 to 135 beats/min was constructed for study population. Based on the formula of Bazett, Fridericia, and Framingham, adjusted QT intervals in these range of heart rates were separately estimated. An adjusting nomogram for different heart rates was created using a reference value, which was the measured QT interval at heart rate of 60 beats/min (QT(No) = QT + correcting number). These four QT correction methods were compared with each other. The reference value of QT interval at heart rate of 60 beats/min was 382 ms. The relationship between QT and RR interval was linear (r = 0.66, P < 0.001). Nomogram method corrected QT interval most accurately for all the heart rates compared with other three adjusting methods. At heart rates of 60-100 beats/min, the equation of linear regression was QT = 237 + 0.158 x RR (P < 0.001). Bazett's formula gave the poorest results at all the heart rates. The formulas of Fridericia and Framingham were superior to Bazett's formula; however, they overestimated QT interval at heart rate of 60-110 beats/min (P < 0.01). At lower rates (<60 beats/min), all methods except nomogram method, underestimated QT interval (P = 0.03)., Conclusion: Among four QT correction formulas, the nomogram method provides the most accurately adjusted values of QT interval for all the heart rates in healthy men. Bazett's formula fails to adjust the QT interval for all the heart rates.

Hypocalcemia is a rare cause of reversible heart failure. We reported a 40-year-old woman who had severe heart failure resistant to the usual antifailure therapy. She had severe hypocalcemia due to hypoparathyroidism after strumectomy. Echocardiography showed a large left ventricle with very low ejection fraction of 25% and moderate mitral regurgitation. After supplementation of calcium and vitamin D, her clinical situation and hemodynamics improved rapidly. At 15 months, myocardial impairment resolved fully. In conclusion, hypocalcemia should be considered in the differential diagnosis of resistant severe heart failure.

Background: We investigated P wave dispersion and left atrial appendage (LAA) function for predicting atrial fibrillation (AF) relapse, and the relationship between P wave dispersion and LAA function., Methods: Sixty-four consecutive patients with AF lasting /=5 days, LA size >/=45 mm, maximum P wave duration >/=112 ms, P wave dispersion >/=47 ms, spontaneous echo contrast, minimum LAA area >/=166 mm(2), and LAA emptying velocity <36 cm/sec were univariate predictors of recurrence (each P < 0.05). By multivariate analysis, LA size (P = 0.02), P wave dispersion (P < 0.001), and LAA emptying flow (P = 0.01) identified patients with recurrent AF. Their positive predictive values were 91, 97, and 72%, respectively., Conclusion: The increased P wave dispersion in addition to the dilated LA and the depressed LAA emptying flow can identify patients at risk of recurrent AF after cardioversion.

The aim of this study was to investigate the angiographic predictors of exercise induced ischemia in patients with isolated coronary ectasia. We have prospectively analysed coronary angiograms of 1521 consecutive patients undergoing cardiac catheterisation. The overall incidence of coronary ectasia was 6.7% (102 patients). Forty-six patients (3%) with non-obstructive, diffuse or segmental coronary ectasia (i.e. isolated coronary ectasia) constituted the main study group. Coronary angiograms were reviewed for stigmata of an impaired coronary blood flow such as 'slow flow', 'segmental backflow phenomenon' and stasis. 'Slow flow' was quantified with frame counting. An ectasia-jeopardy score was also described in order to assess the effect of the extent of coronary ectasia on exercise induced ischemia. Exercise induced ischemia was observed in 24 patients (52%). Exercise test was abnormal in 70% of the patients with diffuse ectasia and 26% of patients with segmental ectasia (p = 0.003). The frame count of the arteries of the study group was higher than the control group but the correlation between the frame count of the ectatic vessels and exercise induced ischemia was not significant. Stasis of the dye also did not correlate with ischemia. There was a significant correlation between exercise induced ischemia and backflow phenomenon in left anterior descending artery (LAD) (r = 0.56, p = 0.0001). Exercise induced ischemia was best correlated with the ectasia-jeopardy score (r = 0.77, p = 0.0001) and a score of > or =4 identified the patients at risk with 90% sensitivity and 80% specificity. In conclusion, the extent of the ectasia within the coronary tree, diffuse ectasia and backflow-phenomenon in LAD were identified as the most important predictors of exercise induced ischemia.

Objective: Since the role of fibrinolytic activity is unclear in coronary artery ectasia, we investigated the entire fibrinolytic activity by a new test, global fibrinolytic capacity (GFC) in the ectasia patients., Methods and Results: Thirty-four ectasia patients (18 male, mean age: 58 +/- 8 years) presenting with acute coronary syndrome and 25 controls (14 male, mean age: 56 +/- 9 years) with normal coronary artery were evaluated. GFC, D-dimer and other hemostatic factors were assessed. Clinical characteristics were comparable in both groups. Serum GFC (4.6 +/- 2.1 vs. 3.1 +/- 2.1 microg/ml, p = 0.03) and D-dimer levels (0.69 +/- 0.42 vs. 0.41 +/- 0.38 ng/ml, p = 0.02, respectively) were significantly higher in ectasia patients than in controls. They were also higher in subgroup of patients with myocardial infarction (four patients) compared with other ectasia patients and controls (p = 0.04, 0.01, respectively). Other hemostatic factors were not different in both groups. GFC was correlated with D-dimer (r = 0.76, p = 0.01)., Conclusion: Our results suggest that fibrinolytic system activation may develop in ectasia patients with acute coronary syndrome. It can be induced by thrombus formation in ectatic segment of coronary artery.

Coarctation of the aorta is one of the congenital heart diseases diagnosed primarily in childhood and early adolescence. A 67-year-old female was admitted to the hospital with chest pain. Angiography revealed a coarctation of the aorta, coronary ectasia and dilatation of the ascending aorta. This case attracted our attention because the first diagnosis was made at such an advanced age and coarctation was accompanied by coronary ectasia and dilatation of the ascending aorta. Therefore, we decided to report the case.

Objective: Left ventricular ejection fraction (EF) and left ventricular (LV) end-systolic diameter measurements are the most widely accepted and utilized methods to demonstrate LV dysfunction in patients with mitral regurgitation (MR). However, these parameters still have many drawbacks in predicting early LV dysfunction. This study investigates the clinical usefulness of tissue Doppler echocardiography technique in detecting early disturbance of myocardial contractility in asymptomatic patients with chronic, severe MR and normal LV ejection fraction values., Methods and Results: Regional systolic peak velocities of mitral annular motion during the ejection phase of systole (SW2) were obtained at the mitral annuli of the ventricular septal, lateral, anteroseptal, posterior, anterior and inferior wall sites in the long axis in 31 asymptomatic patients with severe MR (with a regurgitant volume of more than 50 ml) and with EFs more than 60%. The patients were grouped according to their dP/dt values (more or less than 1300 mmHg/s) estimated non-invasively by using continuous Doppler wave of MR SW2 measurements of Group I were higher than Group II in all of the analyzed segments. The difference was statistically significant for all of the segments. SW2 values of the whole study group was moderately correlated with dP/dt measurements in all of the analyzed segments other than the interventricular septum., Conclusion: SW2 measurements in the long axis, which are considered to be relatively independent from afterload conditions may be helpful in early detection (while EF is still in normal range) of LV systolic dysfunction during the follow-up of patients with chronic MR.

Non-atherosclerotic coronary artery aneurysms are rare and most of them remain asymptomatic. We report a case who has a giant circumflex coronary artery aneurysm with fistulisation into the coronary sinus. The patient presents with dyspnea and palpitation due to atrial fibrillation with rapid ventricular response. The diagnostic contributions of echocardiography, coronary angiography are discussed. The hemodynamic effects of this anomaly are reviewed.

Objective: The incidence of paroxysmal and persistent atrial fibrillation (AF) recurrence is high and unpredictable. In this study, a novel noninvasive method that was thought to reflect the interatrial conduction time was investigated to predict AF recurrence. This method was on the basis of the measurement of time interval from initiation of the electrocardiographic P wave to the start of left atrial (LA) appendage (LAA) ejection flow (P-LAA)., Methods and Results: Forty-five consecutive patients (age, 61 +/- 11 years; 20 male) with newly diagnosed AF (mean duration, 132 hours; range: 6 hours-3 months) who converted to in sinus rhythm spontaneously or with cardioversion were studied prospectively. Transthoracic and transesophageal echocardiography were performed to measure LA size, mechanical functions, LAA ejection velocity, and P-LAA. Transesophageal echocardiography was performed for the measurement of P-LAA 1 to 2 days after conversion to in sinus rhythm. The patients were followed up for a period of 163 +/- 72 days for the recurrence of AF. AF recurred in 17 (38%) patients after a mean time of 81 +/- 67 days. P-LAA was significantly higher in patients with AF recurrence (123 +/- 36 vs 92 +/- 24 milliseconds, P =.0047) and multiple regression analysis indicated that P-LAA was an independent predictor of AF recurrence. Multiple regression analysis revealed no significant differences in LA size parameters, or in clinical and LA mechanical function parameters recorded after restoration of in sinus rhythm between patients with and without AF recurrence., Conclusion: P-LAA may be considered to be an independent predictor of recurrent AF.