Atrial premature complexes and heart rate have prognostic significance in 1-month atrial fibrillation recurrence after electrical cardioversion.

AIMS: The aim of this study was to investigate the significance of simple 24-h Holter (24H) data after electrical cardioversion (CV) for atrial fibrillation (AF) recurrence. METHODS: We prospectively studied 47 consecutive patients subjected to CV, who successfully converted to sinus rhythm. All underwent echocardiography and 24H after CV. AF recurrence was studied at 14 days and 1 month by second 24H or by interim report of AF. RESULTS: About 53.2% remained in sinus rhythm (group I) and the rest recurred to AF (group II). Group I had fewer atrial premature complexes per hour (APC/h) (P = 0.002) and lower maximum (max HR), average, and minimum heart rates compared with group II (all Ps < 0.05). The optimal value of APC/h and max HR with best sensitivity and specificity was 32 APC/h and 90 bpm, respectively. These findings were the predictors of AF recurrence [hazard ratio (HR) = 4.5 with 95% CI = 1.7-11.7 and HR = 4.3 with 95% CI = 1.7-10.9, respectively]. Patients with the combination of both predictors had greater HR of AF recurrence compared with those with < 32 APC/h and max HR < 90 bpm (HR = 8.8 with 95% CI = 2.5-31.4). CONCLUSION: Patients with frequent APC/h and high max HR are at high risk for 1-month AF recurrence after electrical CV.     

Chromosomal aberrations in infective hepatitis

Structural chromosomal aberrations, in the form of breaks, were found in a significantly higher proportion of bone marrow cells in patients with infective hepatitis than in controls. These anomalies were observed during the first and third weeks after the onset of jaundice but had subsided by the sixth week.Chromosomal aberrations did not appear to be related to the severity of infective hepatitis or to the sex or age of the patients.The distribution of chromosomal abnormalities did not appear to be random; they were observed predominantly in the A(2) and B(4-5) series. Since no abnormalities were detected in the G-group chromosomes, no evidence in support of a relationship between infective hepatitis and Down's syndrome was obtained.Numerical chromosomal aberrations were not observed, nor was any evidence obtained that mitotic activity of bone marrow cells is suppressed in patients with infective hepatitis.     

Pectoral cardioverter defibrillators: comparison of prepectoral and submuscular implantation techniques

The purpose of this study was to compare the two techniques of pectoral ICD implantation, prepectoral and submuscular, performed by an electrophysiologist in the catheterization laboratory with use of general or local anesthesia in 45 consecutive patients. Over a period of 30 months, we implanted pectoral transvenous ICDs in 43 men and 2 women, aged 59 +/- 12 years, with use of general (n = 20) or local (n = 25) anesthesia in the catheterization laboratory. Patients had coronary (n = 30) or valvular (n = 4) disease, cardiomyopathy (n = 10) or no organic disease (n = 1), a mean left ventricular ejection fraction of 31%, and presented with ventricular tachycardia (n = 40) or fibrillation (n = 5). One-lead ICD systems (18 Endotak, 10 Transvene/8 Sprint, 2 EnGuard) were used in 38 patients, 2-lead (5 Transvene, 1 EnGuard) systems in 6 patients, and 1 atrioventricular lead ICD system in 1 patient. The prepectoral technique was employed in 29 patients with adequate subcutaneous tissue, while the submuscular technique was used in 16 patients who had a thin layer of subcutaneous tissue. The defibrillation threshold averaged 9-10 J in both groups and there were no differences in pace/sense thresholds. All implants were entirely transvenous with no subcutaneous patch. Biphasic ICD devices were employed in all patients. Active or hot can devices were used in 39 patients. There were no complications, operative deaths, or infections. Patients were discharged at a mean of 3 days. All devices functioned well at predis-charge testing. Over 14 +/- 8 months, 20 patients received appropriate device therapy (antitachycardia pacing or shocks). No late complications occurred. One patient died at 3 months of pump failure; there were no sudden deaths. In conclusion, for exclusive pectoral implantation of transvenous ICDs, electrophysiologists should master both prepectoral and submuscular techniques. One can thus avoid potential skin erosion or need for abdominal implantation in patients with a thin layer of subcutaneous tissue. Finally, there are no differences in pacing or defibrillation thresholds between the two techniques.     

Abnormal signal-averaged electrocardiograms in patients with incomplete right bundle-branch block

Background and hypothesis: A hypothesis was formulated that regional delayed activation of the right ventricle, as seen in incomplete right bundle-branch (IRBBB) aberrancy, may simulate late potential activity and may be responsible for abnormal signal-averaged electrocardiograms (SAECGs). No previous studies have specifically addressed this issue in this particular group of patients (with IRBBB). Therefore, the aim of the present study was to investigate the incidence of abnormal SAECGs in patients with IRBBB. If this were confirmed, our purpose would further be to investigate ways of reducing the false positive results. Methods: The study group included 53 patients (28 men and 25 women), aged 53 ± 13 years, with no history of previous myocardial infarction or ventricular tachycardia and who had an electrocardiogram (ECG) showing IRBBB. An SAECG was also performed in a control group of 19 age-matched individuals with a normal ECG. Time domain analysis was performed using a band pass filter of 40–250 Hz. The following parameters were considered normal: filtered QRS duration (QRSD) < 114 ms, root mean square of the voltage of the last 40 ms of the QRS complex (RMS) > 20 μV, and the duration of the low amplitude signal (< 40 μV) at the terminal portion of the QRS (LAS) < 38 ms. An SAECG was considered abnormal if any two of these criteria were abnormal. Results: The mean values of the SAECG parameters were: QRSD 101 ± 11 ms, RMS 32 ± 20 μV, LAS 32 ± 12 ms, and noise 0.29 ± 0.13 μV. Abnormal SAECGs with at least two criteria satisfied were present in 16 of 53 (30%) patients compared with 0 (0%) of 19 individuals in the control group (p = 0.02). Abnormal values included the combination of RMS and LAS in 12 patients and all three parameters in 4 patients. However, if the definition of late potentials were limited to the combination of abnormal QRSD and either RMS or LAS values, the incidence of false positive results (4 patients) (7.5%) would be significantly decreased (p = 0.007). At 21 months of follow-up, no arrhythmic events occurred. Conclusions: Delayed terminal conduction observed in IRBBB may cause a high incidence of false positive late potentials on SAECGs. Based on this study, we propose that this can be largely remedied if the optimal criteria for the presence of late potentials in patients with IRBBB always include the combination of QRSD and either RMS or LAS.     

Thrombophilic abnormalities of natural anticoagulants in patients with ulcerative colitis

BACKGROUND/AIMS: Ulcerative colitis patients have increased risk for thromboembolic events. Factors predisposing to thrombosis in ulcerative colitis are poorly defined. The aim of this study was to evaluate possible thrombophilic abnormalities in patients with ulcerative colitis. METHODOLOGY: Fifty-one patients with ulcerative colitis and 51 healthy controls were studied. Disease activity, clinical and endoscopic, was assessed by standard criteria. Plasma levels of antithrombin, protein C, free protein S and activated protein C resistance were determined in both study groups. Genetic test for factor V Leiden was performed in cases with abnormal activated protein C resistance. Parameters of inflammation and fibrinogen were additionally measured in ulcerative colitis patients. RESULTS: Mean values of free protein S were significantly lower in ulcerative colitis patients (84.01 +/- 21.57) compared to healthy controls (100.17 +/- 24.7) (p < 0.001). Mean values of protein C were higher in ulcerative colitis patients (124.6 +/- 39.03) than healthy controls (100.19 +/- 19.86) (p < 0.001). No other significant differences were observed, but there was a trend towards higher prevalence of low values for antithrombin (9.8% vs. 0%, p = 0.056) and free protein S (19.6% vs. 5.9%, p = 0.072) in ulcerative colitis patients. Three ulcerative colitis patients and three healthy controls had low activated protein C resistance ratio. All these subjects were heterozygous for factor V Leiden. No correlation was observed between abnormalities in thrombophilic parameters and clinical, endoscopic or inflammatory parameters in ulcerative colitis group. CONCLUSIONS: Abnormalities in natural anticoagulants are more common in ulcerative colitis patients compared to healthy controls, irrespective of disease activity. Low activated protein C resistance ratio due to factor V Leiden is not more common in ulcerative colitis patients than in healthy controls.     

Bilateral primary lymphoma of the breast: a case report initially diagnosed by FNAC

Primary lymphoma of the breast (PLB) is a rare disease, representing 0.04-0.5% of all malignant breast neoplasms. We present a patient with bilateral breast involvement by a high-grade diffuse large B-cell lymphoma, which was diagnosed initially by fine-needle aspiration cytology (FNAC). Mammography revealed a diffuse increase in density of the right breast and a large solitary mass on the left breast, suggestive of an inflammatory carcinoma. The patient underwent FNAC and the diagnosis of a non-Hodgkin's lymphoma (NHL) was suggested. Physical examination revealed palpable bilateral axillary lymph nodes but no evidence of concurrent widespread disease. The patient underwent complete staging evaluation. The only positive findings were an elevated lactate dehydrogenase (LDH) and evidence of axillary lymphadenopathy on CT. Excisional biopsy was performed on the left breast. The morphological and immunohistochemical analysis confirmed the diagnosis of a high-grade diffuse large B-cell lymphoma with an immunophenotype suggestive of a germinal center cell origin.     

Radiofrequency Ablation in Older Children and Adolescents by an Adult Electrophysiology Team

Background: Radiofrequency (RF) catheter ablation has been widely and successfully employed to cure adult patients of a variety of arrhythmias. Only a few centers have a pediatric electrophysiology (EP) service available and have presented similar results in children. The aim of this study was to investigate the efficacy and safety of RF ablation in pediatric patients performed by an adult EP team.Patients and Methods. The study group included 33 consecutive pediatric patients, aged 7–18 years (mean 14.1±3.1), with symptomatic supraventricular tachyarrhythmias, who underwent RF ablation during the last 3 years. All but two patients underwent a full EP study during the same session. Procedures were performed in all but five patients with use of local anesthesia and deep or light sedation. The left heart was approached with use of transaortic (n = 3) or transseptal (n = 7) techniques. RF ablation was performed for manifest (n = 11) or concealed (n = 9) (9 left, 4 anteroseptal, 3 midseptal, and 4 posteroseptal) or right atriofascicular (Mahaim) (n = 1) accessory pathways in 19 patients, 12 slow AV nodal pathways and 2 atrial tachycardia foci in the other 14 patients.Results. RF ablation was successful in all patients (100%) with 1–27 RF applications (mean: 10±7). There was one complication in a patient with 2 accessory pathways; after RF ablation of a posteroseptal accessory pathway, complete heart block occurred during successful ablation of a second midseptal accessory pathway. Fluoroscopy time averaged 35±23 min and procedure duration 2.8±1.4 hours. During long-term follow-up of 19±10 months, there was one AV nodal tachycardia recurrence at 2.5 months, successfully treated with repeat RF ablation.Conclusion. RF ablation in pediatric patients performed by an adult EP team is efficacious and safe offering cure of symptomatic cardiac tachyarrhythmias in this patient population.     

Cardiac and sternocleidomastoid muscle involvement in Duchenne muscular dystrophy: an MRI study

OBJECTIVE: To examine the extent of cardiac muscle and sternocleidomastoid muscle (SCM) involvement detected by MRI measurement of T2 relaxation time in patients with Duchenne muscular dystrophy (DMD) and no cardiorespiratory symptoms. DESIGN: Prospective controlled study. SETTING: Teaching referral hospital and university hospital. SUBJECTS: Seventeen patients with DMD (age range, 7 to 25 years) and 17 age-matched control subjects. All patients were free of cardiac or respiratory complaints and had normal ECG, echocardiograph, and Holter monitor examination findings. METHODS: We assessed respiratory function by means of standard pulmonary function testing. MRI measurements included the T2 relaxation time of the myocardium and the SCM in patients and control subjects. RESULTS: The FVC and FEV1 values were lower in patients with DMD than in age-matched control subjects, whereas the FEV1/FVC ratio was normal in all subjects. Patients with DMD had lower T2 relaxation time of the heart (37.8 +/- 6.1 ms vs 58.1 +/- 7.1 ms, p < 0.001) and lower T2 relaxation time of the right SCM (24.5 +/- 2.6 ms vs 42.2 +/- 1.3 ms, p < 0.001) and left SCM (23.2 +/- 3.2 ms vs 42.2 +/- 1.6 ms, p < 0.001), compared to control subjects (+/- SD). In children (< 12 years of age), the T2 of the SCM was lower than that of the control subjects, but T2 of the heart did not differ between the two groups. In the patient group, T2 relaxation time of the heart decreased with age (r = - 0.80, p < 0.001). In patients with FVC < 80% of predicted, the T2 values of the heart were lower than the T2 values of patients with FVC > or = 80% of predicted (35.6 +/- 5.8 ms vs 41.8 +/- 4.6 ms, p < 0.05). CONCLUSIONS: MRI measurements of the T2 relaxation time in the myocardium and SCM of patients with DMD and no cardiorespiratory symptoms are abnormal, indicating altered tissue composition. These measurements may prove a clinically useful test for monitoring cardiac and respiratory muscle involvement in these patients.     

Hyperhomocysteinemia in ulcerative colitis is related to folate levels

AIM: To study the prevalence and clinical significance of hyperhomocysteinemia (hHcys), an independent factor for arterial and venous thrombosis, in a group of patients with ulcerative colitis (DC). METHODS: Fasting homocysteine (Hcys), folate, and vitamin B12 serum levels were measured in 40 DC patients and 50 healthy controls. Clinical data regarding DC were gathered. RESULTS: Median serum Hcys levels in DC patients were similar to those in controls (12.26 umol/L vs 12.32 μmol/ L), but the prevalence of hHcys was higher in UC patients than in controls (30% vs 10%, P= 0.028).UC significantly increased the risk of hHcys (adjusted odds ratio: 4.125; 95%CI: 1.26-13.44). Multivariate regression analysis showed that male sex, folate and vitamin B12 deficiency or lower serum values were significant independent predictors of higher Hcys levels in UC patients (r2=0.4;P<0.001). CONCLUSION: hHcys is common in UC patients and it is related to folate and vitamin B12 deficiency or lower serum values. It would be reasonable for patients with UC to receive folate and vitamin B complex supplements as a prophylactic measure.