Introduction: Constrictive pericarditis is characterized by constriction of the heart secondary to pericardial inflammation. Cardiovascular magnetic resonance (CMR) imaging is useful imaging modality for addressing the challenges of confirming this diagnosis. It can be used to exclude other causes of right heart failure, such as pulmonary hypertension or myocardial infarction, determine whether the pericardium is causing constriction and differentiate it from restrictive cardiomyopathy, which also causes impaired cardiac filling. Case Presentation: A 77-year-old man from a country with high incidence of tuberculosis presented with severe dyspnea. Echocardiography revealed a small left ventricle with normal systolic and mildly impaired diastolic function. Left heart catheterization revealed non-obstructive coronary disease, not felt contributory to the dyspnea. Anatomy imaging with cardiovascular magnetic resonance imaging (CMR) showed global, severely thickened pericardium. Short tau inversion recovery (STIR) sequences for detection of oedema/ inflammation showed increased signal intensity and free breathing sequences confirmed septal flattening on inspiration. Late gadolinium imaging confirmed enhancement in the pericardium, with all findings suggestive of pericardial inflammation and constriction. Conclusions: CMRwith STIRsequences, free breathing sequences and late gadolinium imaging can prove extremely useful for diagnosing constrictive pericarditis.

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Background: Breathlessness is a common problem in chronic heart failure (CHF) patients, and respiratory muscle strength has been proposed to play an important role in causing breathlessness in these patients. Objectives: The aim of this study was to investigate the relation between respiratory muscle strength and the severity of CHF, and the influence of respiratory muscle strength on abnormal ventilation during exercise in CHF patients. Patients and Methods: In this case series study, we assessed clinically stable CHF outpatients (N = 66, age: 57.7 ± 14.6 years). The peak oxygen consumption (peak VO₂), the slope relating minute ventilation to carbon dioxide production (VE/VCO₂ slope), and the slope relating tidal volume to respiratory rate (TV/RR slope) were measured during cardiopulmonary exercise testing. Respiratory muscle strength was assessed by measuring the maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Results: The MIP and MEP decreased significantly as the New York Heart Association functional class increased (MIP, P = 0.021; MEP, P < 0.01). The MIP correlated with the TV/RR slope (r = 0.57, P < 0.001) and the VE/VCO₂ slope (r = -0.44, P < 0.001), and the MEP also correlated with the TV/RR slope (r = 0.53, P < 0.001) and the VE/VCO₂ slope (r=-0.25, P < 0.040). Stepwise multiple regression analysis revealed that age and MIP were statistically significant predictors of the TV/RR and VE/VCO₂ slopes (both P < 0.05). Conclusions: Respiratory muscle strength is related to the severity of CHF, and associated with rapid and shallow ventilation or excessive ventilation during exercise.

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Background: Subclinical hypothyroidism (SH) is diagnosed biochemically by the presence of normal serum free thyroxine concentration, in conjunction with an elevated serum thyroid-stimulating hormone level. Recent studies have demonstrated the frequent association between SH and cardiovascular diseases and risk factors. Objectives: To evaluate the impact of SH on patterns of circulating endothelial-derived microparticles, (EMPs) among chronic heart failure (CHF) patients Patients and Methods: This is a retrospective study involving a cohort of 388 patients with CHF. Fifty-three CHF subjects had SH and 335 patients were free from thyroid dysfunction. Circulating levels of N-terminal-pro brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), thyroid-stimulating hormone (TSH), total and free thyroxine (T4), and triiodothyronine (T3), and endothelial apoptotic microparticles (EMPs), were measured at baseline. SH was defined, according to contemporary clinical guidelines, as a biochemical state associated with an elevated serum TSH level of greater 10 μϋ/L and normal basal free T3 and T4 concentrations. Results: Circulating CD31+/annexin V+ EMPs were higher in patients with SH compared to those without SH. In contrast, activated CD62E+ EMP numbers were not significantly different between both patient cohorts. Using uni (bi) variate and multivariate age- and gender- adjusted regression analysis, we found several predictors that affected the increase of the CD31+/annexin V+ to CD62E+ ratio in the patient study population. The independent impact of TSH per 6.5 μϋ/L (odds ratio [OR] = 1.23, P = 0.001), SH (OR=1.22, P = 0.001), NT-proBNP (OR= 1.19, P = 0.001), NYHA class (OR=1.09, P = 0.001), hs-CRP per 4.50 mg/L (OR = 1.05, P = 0.001), dyslipidemia (OR=1.06, P = 0.001), serum uric acid per 9.5 mmol/L (OR=1.04, P = 0.022) on the increase in the CD31+/annexin V+ to CD62E+ ratio, was determined. Conclusions: We believe that the SH state in CHF patients may be associated with the impaired pattern of circulating EMPs, with the predominantly increased number of apoptotic-derived microparticles.

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Background: Acute heart failure (AHF) is defined as the new onset or recurrence of gradual or rapidly worsening signs and symptoms of heart failure, requiring urgent or emergent therapy. Objectives: This study attempts to assess the association of liver function tests (LFT) and uric acid level with in hospital outcome and echocardiography parameters, in patients with acute decompensated heart failure. Patients and Methods: A total of 100 patients (aged 16 - 90 years, 60% men) admitted with AHF were enrolled. LFTs and uric acid levels were assessed on first day and before discharge, and patients were followed for 3 months. Results: In-hospital outcomes were considered. Mean Left Ventricular Ejection Fraction (LVEF) was 35% (20 - 45%). Mean Uric acid level was 8.4 mg/dL, significantly higher than chronic HF and normal groups (P < 0.02). Elevated liver enzymes were seen in 52% patients, mostly (87%) in transaminases. Liver enzymes were decreased in 85% patients before discharge. LFT and uric acid levels were inversely and significantly correlated with LVEF on echocardiography (P = 0.02), but not with diastolic parameters. Although there was no significant correlation between uric acid level and in-hospital mortality, risk of intubation and rehospitalization in 3 months, enzyme levels increased in these groups. Increased aspartate transaminase (AST level) was associated with inotrope infusion in AHF patients (42 vs. 82 mg/dL, P = 0.03). Conclusions: Abnormal transaminases and uric acid levels are seen in AHF patients. Increased AST levels may be a predictor of the need for inotrope during hospital course in these patients.

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Background: The head-up tilt test (HUTT) is a useful diagnostic tool for syncope. Objectives: We sought to investigate the outcome of the HUTT in syncope patients and identify the relationship between age and different hemodynamic outcomes. Patients and Methods: In this cross-sectional study, we prospectively enrolled consecutive patients who presented with syncope and underwent the HUTT with a clinical suspicion of neurocardiogenic syncope after the exclusion of orthostatic hypotension cases. The HUTT consisted of consecutive passive and active phases. In the passive phase, the patients were tilted at 70 degrees for 20 minutes; and if negative, the test was repeated with 400 micrograms of sublingual nitroglycerin for another 20 minutes. Positive responses were classified according to the classification of the vasovagal syncope international study (VASIS) and compared for age and gender. Results: A total of 498 patients were enrolled (age = 44.93 ± 18.77 years; male = 271 [54.4%]). Overall, 291 (58.4%) patients had a positive HUTT, while 256 (88.5%) patients had a positive result during the active phase. The test results were as follows: 107 (36.7%) mixed type (VASIS I), 103 (35.3%) cardioinhibitory (VASIS IIA = 44 [15.1%]; VASIS IIB = 59 [20.2%]), and 80 (27.4%) vasodepressive (VASIS III). There was no relationship between gender and syncope type. The trend of the HUTT result significantly changed with age, and the rate of cardioinhibitory syncope decreased after middle ages (P value for trend = 0.02). Conclusions: Hemodynamic response to the HUTT was associated with age. Cardioinhibitory response became less frequent with age due to exaggerated vagal activity in the younger patients as compared with the older subjects.

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Background: During the four steps of the Valsalva maneuver (VM), opposite changes can be observed in some physiologic parameters. Manifestations of the VM in the electrocardiogram (ECG) have been studied in detail, but there have been few reports comparing VM- related biochemical and hemodynamic changes with a focus on the strain phase of the VM. Objectives: We studied strain-related ECG changes during the VM. Patients and Methods: This self-control descriptive study was conducted in 20 healthy male college students aged 20.12 ± 2.23 years. They were well trained to perform the standard VM: maintenance of a 15-second expiratory pressure at 40 mmHg with open glottis. An ECG was continuously recorded in the supine position at (a) rest (before the VM) and at (b) the start and (c) end of strain maintenance in the second phase of the VM. The averages of four successive beats were computed for each set of (a), (b), and (c). Means ± standard errors of the mean were used for comparison. Results: Following the VM, the RR and PR intervals, corrected QT interval (QTc), P wave duration and amplitude, T wave amplitude, and the ratio of T/R amplitudes showed significant changes. The QRS duration and R wave amplitude did not show significant changes. Conclusions: The VM caused time and voltage changes in some ECG waves during the strain phase. Alterations in heart or lung volume, electrode-related alterations, and autonomic tone may cause these changes.

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Background: Subdiaphragmatic activity can produce subdiaphragmatic-related artifacts, which can degrade the quality of myocardial perfusion imaging (MPI). Objectives: We examined the impact of drinking milk, water, and lemon juice on different subdiaphragmatic-related artifacts by using ^99mTc-sestamibi myocardial single-photon emission computed tomography (SPECT) in order to determine a feasible method for improving the image quality. Patients and Methods: A total of 179 patients (age 58 ± 9.6 years) were enrolled in this study. The patients were randomly divided into five groups. Ten minutes after injection of 740 MBq 99mTc-sestamibi in both pharmacologic stress and rest phases, the individuals in group 1 were given water and milk (125 mL of each); those in group 2 were given lemon juice (250 mL); group 3 was given milk (250 mL); and group 4 was given water (250 mL), whereas no intervention was performed in group 5. The study was double-blind for both subjects and data collectors. MPI was performed for all patients and image quality was controlled by 2 experienced nuclear physicians. Interfering activity was determined visually on reconstructed images and categorized as extracardiac normalization artifact, overlapping of activity, scattering of activity, and ramp filter artifact. Results: There were significant differences in terms of interfering activity among the five groups; group 3 (milk) had significantly lower interfering activity than other groups had, as defined by overlapping of activity (on both stress and rest images), ramp filter artifact (stress images), and scatter artifact (rest images) (P < 0.05). Furthermore, there was a significant difference in the incidence of good-quality images, with no interfering activity in group 3 in the resting state compared with the other groups in the study (P < 0.05). Conclusions: Drinking 250 mL of milk in either the stress phase or the rest phase of imaging diminishes interfering subdiaphragmatic- related artifacts, particularly overlapping of activity in MPI SPECT, resulting in better-quality images.

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Background: Acute pulmonary vasoreactivity testing has been recommended in the diagnostic work-up of patients with idiopathic pulmonary arterial hypertension (IPAH). Pulmonary arteriolar capacitance (Cp) approximated by stroke volume divided by pulmonary pulse pressure (SV/PP) is considered as an independent predictor of mortality in patients with IPAH. Objectives: We sought to evaluate any differences in baseline and adenosine Cp between vasoreactive and non-vasoreactive IPAH patients tested with adenosine. Patients and Methods: Fourteen patients with IPAH and a vasoreactive adenosine vasoreactivity testing according to the ESC guidelines were compared with 24 IPAH patients with nonreactive adenosine test results. Results: There were no statistical significant differences between the two groups regarding NYHA class, body surface area, heart rate, and systemic blood pressure during right heart catheterization. Hemodynamic study showed no statistical significant differences in cardiac output/Index, mean pulmonary artery pressure, pulmonary vascular resistance, and baseline Cp between the two groups. There was a statistical significant but weak increase in adenosine Cp in vasoreactive group compared to non-reactive group (P = 0.04). Multivariable analysis showed an association between Cp and vasoreactivity (Beta = 2, P = 0.04, OR = 0.05 (95%CI = 0.003 - 0.9). Conclusions: Cp could be considered as an index for the prediction of vasoreactivity in patients with IPAH. Prediction of long-term response to calcium channel blockers in patients with IPAH and a positive vasoreactive test by this index should be addressed in further studies.

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Introduction: Left ventricular free wall rupture (LVFWR) is a frequent cause of death after acute myocardial infarction, and its repair remains a surgical challenge. Case Presentation: TachoSil^® is a ready-to-use equine collagen patch which has been successfully used for hemostasis in cardiovascular surgery. However, a limited number of studies have reported its application for LVFWR repair. In this study, we describe our initial experience using TachoSil^® for LVFWR repair. Conclusions: A hemodynamic study was acceptable at a 12-month follow-up, and no complication was seen.

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