852 e-Letters

  • Great Relief to the Doctors and Patients Alike!

    There had been controversies raging whether Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blocking Agents may be harmful, neutral or protective to the people affected by SARS-CoV-2.
    The findings of this study, especially because it encompasses such huge study population will provide great relief from uncertainty and anxiety to the doctor's prescribing these class of medicines to their hypertensive patients and to the people alrady taking these medicines.
    Great many sinceremost thanks to the investigators of this study!
    -Arvind Joshi;
    Founder Convener and President:
    Our Own Discussion Group (OODG);
    602-C, Megh Apartments;
    Ganesh Peth Lane, Dadar West, Mumbai; Maharashtra State,INDIA, PIN 400028;
    Consultant Physician at:
    Ruchi Clinical Laboratory/Ruchi Diagnostic Center, Sunshine CHS,
    Plot 58, Sector 21, Kharghar;
    Maharashtra State, INDIA, PIN 410210.

  • Biphasic ventilation for failing Fontan physiology

    Biphasic ventilation for failing Fontan physiology

    Seigo Okada1, MD, PhD, Jun Muneuchi1, MD, PhD, Mamie Watanabe1, MD

    1Department of Pediatrics, Japan Community Healthcare Organization, Kyushu Hospital, 1-8-1, Kishinuora, Yahatanishiku, Kitakyushu, Fukuoka, 806-8501, Japan

    Address correspondence and reprint requests to: Seigo Okada, M.D., Ph.D.
    Department of Pediatrics, Japan Community Healthcare Organization, Kyushu Hospital, 1-8-1, Kishinoura, Yahatanishiku, Kitakyushu, Fukuoka, 806-8501, Japan. Tel: 81-93-641-5111; Fax: 81-93-642-1868; E-mail: sokada0901@gmail.com; ORCID: 0000-0002-9150-1913

    Dear Editor:
    We read the article by Charla et al.1 with great interest. The authors conducted a phase-contrast magnetic resonance study during biphasic ventilation (BPV) in 10 patients aged 20–34 years who had Fontan circulation and 10 matched control subjects. BPV resulted in significant pulmonary blood flow and cardiac output augmentations in the Fontan group, which suggests the importance of “thoracic pump” in Fontan patients without a subpulmonary ventricle. We appreciate the authors’ efforts to assess the efficacy and feasibility of noninvasive external ventilation for Fontan patients. This is a thoughtfully conducted study, but some issues must be further discussed.
    First, the authors mentioned that the study was the first to describe the impact of BPV in the Fontan population. However, we...

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  • Response to: “Non-infective endocarditis”


    We read with interest the review of non-infective endocarditis by Hurrell et al. [1] and would like to report our experience. We recently reported the case of an asymptomatic, hypertensive 36-year-old man who was found to have a mobile structure attached to the posterior mitral valve leaflet causing moderate eccentric regurgitation on routine echocardiography [2]. Extensive workup was only notable for strongly positive cardiolipin IgG and IgM antibodies and lupus anticoagulant suggesting a diagnosis of antiphospholipid antibody (APLA) syndrome. We referred the patient for surgical intervention (excision and mitral valve repair with a bovine pericardial patch) and this also allowed us to achieve a diagnosis. Histological features were typical of nonbacterial thrombotic endocarditis (NBTE) with fibrin deposits, inflammatory cells and erythrocytes and confirmed an underlying diagnosis of primary APLA syndrome.
    The association of APLA syndrome with or without autoimmune disease increases prothrombotic tendency and these patients therefore have a higher likelihood of NBTE which can remain clinically silent. We therefore propose that transthoracic echocardiography should be used as a screening and surveillance tool for NBTE in all patients who are found to have primary or secondary APLA syndrome and potentially in patients with autoimmune disease and hypercoaguable states. We also emphasize consideration of a histological diagnosis when there is diagn...

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  • A new role for exercise echocardiography? Can we abandon athletic deconditioning advice?

    The benefits of regular exercise are non deniable with reduction in all cause, cardiovascular and cancer mortality (1,2,3). Endurance exercise with increase in cardiac output results in dilatation of left ventricular cavity size and eccentric hypertrophy with low normal ejection fraction that is a dilated cardiomyopathy phenocopy. The ability to distinguish true pathology from physiological remodelling remains a difficult area for cardiologists. Frequently asymptomatic athletic individuals are referred to the cardiology service with abnormal resting 12 lead ECGs. They must be appropriately investigated. The dimema for the investigating cardiologist is to determine the healthy athlete from the athlete with DCM. An erroneous diagnosis of DCM in an athlete may lead to unnecessary disqualification from sport, unnecessary pharmacotherapy and a decline in physical and psychological well being as well as implications for life insurance. Millar et al study adds vital information to the field (4). It is reassuring that the study reported that none of the athletes with a physiologically increased LV size and borderline or low resting LV ejection fraction (grey-zone participants) had replacement fibrosis of the left ventricular myocardium on cardiac MRI. In addition, the authors have reported that functional assessment of the heart by stress echocardiography can discriminate between DCM and DCM phenocopy with high sensitivity and specificity. This study will likely be a game...

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  • narroe complex ventricular tachycardia should be included in the differential diagnosis

    For the sake of completeness, the approach to narrow complex tachycardia(1), and the differential diagnosis of that disorder, should also include the entity of fascicular ventricular tachycardia, in which the duration of the QRS complex does not exceed 120 ms during ventricular tachycardia(VT)(2)(3). There are 3 subtypes, namely, left posterior fascicular VT with right bundle branch(RBBB) morphology and left axis deviation, left anterior fascicular VT with RBBB pattern and right axis deviation, and upper septal fascicular VT with a narrow QRS and normal axis configuration(2).
    Talib et al evaluated 10 patients aged 14-66 with upper septal ventricular tachycardia in whom there was no structural heart disease, and in whom the QRS duration amounted to < 120 ms during VT. In 8 instances VT could be terminated by administration of verapamil. In the other 2 instances no attempt had been made to terminate the episodes of VT with that drug. In the verapamil-responsive subjects, the episodes of VT were characterised by QRS duration amounting to 75 ms, 90 ms(two patients), 93 ms, 96 ms, 105 ms, 115 ms, and 118 ms, respectively. In 4 patients precordial QRS configuration during VT was identical to QRS configuration during sinus rhythm. In the other four, QRS configuration was of the RBBB subtype during VT(3).
    Narrow complex VT can also be a manifestation of coronary artery disease, but, in this context, there appears to be no involvement of the His-Purki...

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  • Stress echocardiography a low cost alternative to CTFFR

    The authors (Nazir et al) of the review of CT fractional flow reserve published in Heart are to be congratulated on very well balanced and well written review of this relatively new technology (1).

    We would like to raise a couple of points regarding imaging stress tests functioning as a gatekeeper to invasive coronary angiography after a stenosis is identified on CTCA. A recent survey of UK cardiologists identified imaging stress tests as the most common approach to assess the functional significance of a moderate stenosis (50-70%) on CTCA, with only 2% electing to use CT-FFR (2). The current increase in the use of CT-FFR is because it is nationally funded. Importantly, stress echocardiography is a very low cost test with a national tariff of £177, which compares favourably with the new reduced tariff for CT-FFR of £530. With time, this may be re-balance in favour of CT-FFR if the tariff drops further, particularly given the attraction of a single patient episode and with an anticipated growth of cardiac CT in line with NICE recommendations.

    It is important to remind readers that the PLATFORM (3) trial compared CTCA plus CT-FFR versus the standard of care in patients with stable chest pain. The patients were divided into an invasive sub-study (n=380) and a non-invasive sub-study (n=204) and the end point of the study was reduction of invasive coronary angiography that showed no obstructive CAD. In the non-invasive sub-study there was no difference in the r...

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  • Specification of criteria for diagnosis of prosthetic valve endocarditis is fundamental

    A review of comparative incidence of infective endocarditis in bioprosthetic vs mechanical valves (1) can only be complete if there is a clear statement of the criteria for the diagnosis of infective endocarditis. An important characteristic of prosthetic valve endocarditis is that "the diagnosis[of endocarditis] is more difficult in the presence of a prosthetic valve when compared with a native valve" due to the fact that "the Duke criteria have been shown to be less helpful in prosthetic valve endocarditis because of lower sensitivity in this setting"(2). Furthermore,
    the diagnostic accuracy of some imaging modalities is suboptimal in prosthetic valve endocarditis(3). According to the latter review , among patients with suspected prosthetic valve endocarditis sensitivity of transthoracic echocardiography can be as low as 17%-36%. For transoesophageal echocardiography(TOE) that parameter increases to 82-96%, the latter statistic comparable to the sensitivity associated with 18 Fluorodeoxyglucose positron emission tomography/CT(PET/CT). Also in the context of prosthetic valve endocarditis, TOE and PET/CT also have comparable specificities in the range 80-96%(3). The major limitation of TOE is that it is invasive and also operator dependent. By contrast PET/CT not only increases the sensitivity of the modified Duke criteria from 70% to 97%(without affecting specificity) but that modality also identifies metastatic septic embol...

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  • Low thromboembolic risk does not necessarily rule out risk of complications of undiagnosed coexisting high-grade carotid artery stenosis

    Regardless of the conclusions of the authors regrading thromboembolic risk(1), atrial fibrillation patients with CHA2DS2 Vasc score of zero or 1 cannot be pronounced to be at truly low risk of stroke unless coexisting high-grade carotid artery stenosis(CAS) has been ruled out. According to one study, among patients with nonvalvular atrial fibrillation(NVAF) who are older than 70 years, the frequency of high grade carotid stenosis(stenosis of 50% or more) is 12% in men and 11% in women(2). High-grade CAS, in turn, is an important risk factor for stroke. Potentially modifiable risk factors for CAS-related stroke include smoking, hypertension, diabetes mellitus, and hyperlipidaemia(3). According to an observational study of subjects with asymptomatic high-grade CAS, progression of the severity of CAS can be mitigated by optimally controlling those risk factors(4). Accordingly, the management of NVAF subjects with CHA2DS2 Vasc score of zero or 1 should include screening for CAS, and optimal control of hypertension, diabetes, and low density lipoprotein levels, over and above cessation of smoking, in the event of a diagnosis of coexisting high-grade CAS. There is also a diagnostic advantage from awareness of the coexistence of high-grade CAS in a patients with zero or 1 CHA2DS2 Vasc score. If such a patient experiences an ischaemic stroke characterised by a cerebral infarct ipsilateral to the high-grade CAS the appropriate management would be prompt prescription o...

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  • Time for action in the broadest sense

    Given the fact that high-sensitivity cardiac troponin is a parameter prevalent, not only in acute myocardial infarction(AMI)(1), but also in close mimics of AMI such as pulmonary embolism(PE)(2) and dissecting aortic aneurysm(DAA)(3), respectively, it is now time for action to be taken to include point-of-care transthoracic echocardiography(TTE) in the algorithm for triaging patients who present with the association of chest pain and an electrocardiogram simulating ST segment elevation myocardial infarction(STEMI). PE subgroups with STEMI-like presentation and DAA subgroups with STEMI-like presentation are each likely to have subsets of subjects with TTE stigmata unique to PE(4) and to DAA(5), respectively, which enable them to be differentiated from subjects with AMI, thereby mitigating the risk of inappropriate percutaneous coronary intervention. When patients with suspected AMI are triaged towards the observation zone that should also be an opportunity to elicit stigmata that might favour a diagnosis of either PE or DAA. For PE those stigmata can be elicited by invoking the Wells clinical decision rule(6), and also by specifically looking for clinical stigmata of deep vein thrombosis(7), and even triggering a Doppler scan of the lower limbs(7), and where appropriate, the upper limbs as well.
    For DAA the "red flags" to look for include interarm blood pressure difference(8), the murmur of aortic regurgitation(9), and mediastinal widening(10)(11), the...

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    Kenan YALTA, MD a
    Ertan YETKIN, MD b
    Gokay TAYLAN, MD a
    Tulin YALTA, MD c

    a Trakya University, Cardiology Department, Edirne, TURKEY
    b Istinye University, Liv Hospital, Cardiology Department, Istanbul, TURKEY
    c Trakya University, Pathology Department, Edirne, TURKEY

    Corresponding Author: Kenan YALTA Trakya University, Cardiology Department, Edirne, TURKEY
    Email- kyalta@gmail.com, akenanyalta@trakya.edu.tr Phone: 00905056579856

    Acute myocardial injury has been suggested as an important prognostic factor in Covid-19 patients (1-3). In their recently published article (1), Wei JF, et al. have demonstrated a significant association of acute myocardial injury (defined as elevation of high sensitive troponin-T (hs-TnT) levels) with older age, pre-existing cardiovascular disease, disease severity (and hence; general frailty) and adverse prognosis in Covid-19 patients . The authors have principally attributed this injury to certain factors including systemic inflammation, hypoxemia and direct myocardial invasion by the viral agent (1). However, as described below, an acute autoimmune reaction triggered by the virus might also be considered as an alternative mechanism of myocardial injury par...

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