Cihan Cevik

Heyde's syndrome is an uncommon association between aortic stenosis and gastrointestinal bleeding. Although initially described during the late 1950s, with subsequent reports of a possible link between these disorders, controversy persists regarding the incidence, pathogenesis, and treatment of this syndrome. The main disagreements center on the actual association of aortic stenosis and angiodysplasia, though other controversies include the pathogenesis of Heyde's syndrome, ranging from von Willebrand factor deficiency and age-related degeneration to mucosal ischemia and cholesterol embolization. A variety of treatment modalities of the syndrome has been applied, including medical management, endoscopic therapy, embolization, and aortic valve replacement. Here, the controversies surrounding Heyde's syndrome, which focus on pathogenesis and treatment, are reviewed with the aim of providing a clearer understanding of the syndrome and the implications for patient care.

Functional mitral regurgitation (FMR) is commonly encountered in patients with heart failure, and is associated with an adverse prognosis. It is hypothesized that left ventricular (LV) and papillary muscle systolic dyssynchrony causes diastolic mitral regurgitation (DMR) in non-ischemic dilated cardiomyopathy (DC) patients. A total of 77 patients with non-ischemic DC was enrolled, of whom 25 were without DMR (group I) and 52 with DMR (group II). Mitral valve apparatus measurements were calculated using two-dimensional echocardiography, while LV/papillary muscle (Pap-index) systolic dyssynchrony parameters were calculated using tissue Doppler echocardiography. The FMR volumes were similar between the two groups (19.4 +/- 10.6 and 22.4 +/- 11.1 ml/beat in groups I and II, respectively). Both groups had similar mitral valves, as assessed by the geometry of the mitral valve apparatus parameters, including tent area, mitral annulus diameter, and tethering distance. However, the maximal intraventricular mechanical delay (MIMD; p < 0.001), peak (+/- SD) myocardial sustained systolic velocity (Ts-SD; p < 0.001) and Pap-index (p < 0.001) were each significantly increased in group II. Strong correlations were apparent between DMR and dyssynchrony parameters [(Ts-SD; r = 0.74, p < 0.001), MIMD (r = 0.78, p < 0.001) and Pap-index (r = 0.78, p < 0.001)]. Linear regression analysis revealed the MIMD (OR 2.94, 95% CI 2.7-6.6, p < 0.001), Ts-SD (OR 3.6, 95% CI 1.2-3.5, p < 0.001) and Pap-index (OR 2.2, 95% CI 1.27-1.35, p = 0.001) to be independent predictors of DMR. In patients with non-ischemic DC, DMR may serve as a useful indicator of mechanical LV/papillary muscle dyssynchrony, especially when used in combination with the other echocardiographic parameters.

Isovolumic acceleration assessed by tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects. Seventy-eight obese subjects (BMI >30 kg/m2; 57 women, 21 men; mean age 51±8 years) were prospectively enrolled. Fifty patients (64.1%) had hypertension and 33 patients (42.3%) had diabetes mellitus. All the subjects were assessed by conventional and tissue Doppler echocardiography. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were determined. Isovolumic contraction wave was defined as the preceding wave of the systolic wave that began before the peak of the R wave on the electrocardiogram. Myocardial isovolumic acceleration was measured by dividing the peak velocity by the time passed from the onset of the wave (zero-crossing) during isovolumic contraction to the peak velocity of the wave. Waist circumference was in positive correlation with left ventricular end-systolic (r=0.22, p=0.047) and end-diastolic (r=0.384, p=0.001) diameters, and in negative correlation with the peak systolic velocity of the tricuspid annulus (r=-0.311, p=0.006). Although hypertensive and normotensive (n=28) obese subjects had similar myocardial velocities, lateral tricuspid annular isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) were significantly lower in hypertensive patients. Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive obese patients.

Cabergoline, an ergot-derived dopamine receptor agonist, is used widely in the treatment of Parkinson's disease (PD) and hyperprolactinemia, but may cause heart valve fibrosis, retraction, and clinically significant regurgitation in PD patients. While cabergoline has been used at much lower doses in patients with hyperprolactinemia, controversy persists as to whether it may cause heart valve disease in this situation. Cabergoline is also used in acromegaly at doses similar to those used in hyperprolactinemia. The case is reported of a female patient with acromegaly who had been taking low-dose (0.5 mg/day) cabergoline for one year, and presented with signs and symptoms of right-sided heart failure. Echocardiography revealed a thickened and retracted tricuspid valve associated with severe tricuspid regurgitation and enlargement of the right-heart chambers. The morphology of the tricuspid valve was typical for cabergoline-related valvulopathy. Cabergoline may not be totally safe even at lower doses, and close echocardiographic monitoring is recommended in patients receiving cabergoline treatment, regardless of the dose level employed.

Implantable cardioverter defibrillator (ICD) therapy reduces sudden cardiac death rates and reduces mortality in patients with ischemic heart disease and low ejection fractions. One‐third of the deaths in patients with nonischemic cardiomyopathy are sudden. However, the efficacy of ICDs in the primary prevention of death in these patients is less clear. The most common cause of mortality in patients treated with ICDs is heart failure progression. ICD shocks can cause direct myocardial injury, fibrosis, inflammation, and adverse psychological outcomes, and these changes may contribute to the ventricular dysfunction in patients who already have a significantly depressed ejection fraction. We have reviewed the published randomized controlled trials and meta‐analysis of prophylactic ICD therapy in the primary prevention of death in patients with nonischemic cardiomyopathy. The individual randomized controlled trials do not report a statistically significant reduction of mortality unless the ICD treatment is added to cardiac resynchronization therapy, but the meta‐analysis did show a significant mortality reduction and favored ICD therapy in these patients. Medical management of many study participants was suboptimal, at least based on current guidelines. The patients with non‐ischemic cardiomyopathy have good outcomes with medical therapy, and ICD therapy in this relatively low‐risk population needs better selection criteria. Copyright

We present a patient with abnormal origin of the right coronary artery from the left anterior descending artery. The patient had chest pain probably related to myocardial ischemia. This anomaly is very rare and has only been reported in a few cases. The abnormal vessel had a rightward course following its take-off from the left anterior descending artery and remained anterior to the main pulmonary artery. There was no significant obstruction. The mechanism of myocardial ischemia remains unexplained.