Abstract Introduction Thrombosis of the intracardiac part of a permanent pacemaker lead, which is usually detected during a routine transthoracic echocardiographic examination, can be totally asymptomatic. The differential diagnosis between intracardiac lead thrombosis and vegetation is crucial, especially in febrile patients, as these two situations are totally different regarding prognosis and treatment. Case presentation We describe the case of an 85-year-old patient with a dual chamber pacemaker (DDDR) due to complete heart block, who was admitted twice, within 2 years, with vegetation-like masses attached to the ventricular lead of the pacemaker. Infective endocarditis was not documented (diagnostic criteria were not fulfilled), although clinical suspicion was high during both hospitalizations. Masses resolved under applied treatment (anticoagulation) in both cases. Discussion Differential diagnosis between lead thrombosis and vegetation was ambiguous in both hospitalizations. Τhe 18F-fluorodeoxyglucose positron emission tomography/computed tomography during the 2nd hospitalization excluded a possible inflammatory origin of the masses.

Key Clinical MessageAmong implantable cardioverter‐defibrillator (ICD) recipients, there are patients with recurrent episodes of electrical storm (ES), retractable to the optimal antiarrhythmic drug therapy or invasive ablation procedures. A relatively novel anti‐ischemic drug with also antiarrhythmic properties, ranolazine, may effectively suppress ventricular arrhythmias in such patients for a long period of time.

We present a case of a 51-year-old male with acute anterior myocardial infarction, who was transferred to our hospital under mechanical ventilation, after resuscitation due to cardiopulmonary arrest. The patient underwent urgent coronary angiography, which showed total thrombotic occlusion of the proximal segment of the left anterior descending (LAD) coronary artery disease. During primary percutaneous coronary intervention (PPCI), thrombosis extended into the left main coronary artery (LMCA), the LAD and the left circumflex artery (LCx) coronary arteries, causing severe hemodynamic compromise. This devastating complication was successfully managed with intracoronary administration of antithrombotic and antiplatelet drugs, as well as thrombus aspiration. We herein discuss the possible mechanisms of this complication and highlight its prevention and treatment.

An 86-year-old male with dizziness and dyspnea due to cardiac tamponade, underwent pericardiocentesis under ultrasound guidance. The procedure was done through the 5th intercostal space at the left sternal border. A 6-F sheath was placed in the pericardial sac. Although only a minimal quantity of pericardial fluid could be removed through the sheath, complete evacuation of the pericardial fluid could be detected with echocardiography, a few minutes after the puncture of the sac. Clinical improvement with hemodynamic stability were present after the procedure. We discuss the mechanism of this strange phenomenon.

H ypertension is a heterogeneous disorder with a number of welldefined as well as putative etiologies. The World Health Organization estimates that hypertension may cause 7.1 million premature deaths and 4.5% of the disease burden worldwide. Hypertension is a major risk factor for stroke and cardiovascular diseases, and is thus associated with significant morbidity and mortality. Hypertensive heart disease is a complex entity that involves changes to the cardiovascular system resulting from arterial hypertension; it is therefore the major cause of hypertension-related complications. The development of Doppler echocardiography has offered new approaches regarding both insights into pathophysiology and clinical implications that affect hypertensive patients. For these reasons, it is obvious that echocardiographic assessment is very important in the clinical management of a hypertensive patient. We aimed at reviewing “old” and newer data regarding the contributions of echocardiography to the evaluation of a hypertensive patient.

Background: Significant evidence shows that elevated heart rate (HR) is an independent risk factor in patients with coronary artery disease (CAD) and influences their prognosis. In addition, patients with chronic obstructive pulmonary disease (COPD) have more frequent episodes of angina and their compliance with heart rate agents, such as beta blockers, is poor. The purpose of the multicenter observational RYTHMOS study was to evaluate the role of heart rate management in the prognosis and quality of life in patients with CAD and COPD. Methods: Baseline data from 280 patients, enrolled in 22 hospitals representing all types of hospital and all geographical areas of the country, were analyzed. All patients had either a prior myocardial infarction or angiographically documented CAD, and COPD verified either after spirometry or from a clinical evaluation by pulmonologists. Results: The mean age of the enrolled patients was 71.8 +/- 9.3 years, 76% were males, mean body mass index was 28.6 +/- 7.9 kg/m(2), 76.3% had hypertension, 31% had diabetes mellitus, and 53.5% of them suffered from heart failure. About 31% of the patients had an angina episode the week before the enrollment and the Canadian Cardiovascular Society (CSS) classification was class I, II, III and IV in 55%, 30%, 14% and 1%, respectively. The mean resting HR was 72.5 bpm; 51% of the patients had resting HR > 70 bpm and 22% of them had HR >= 80 bpm. Only 52.8% of the study patients were receiving beta-blockade (BB) therapy; they were more likely to have resting HR <= 70 bpm (57.4% vs. 42.7%, p < 0.001). 16.4% of the patients were receiving ivabradine and they had a higher initial HR compared to the others (78.5 vs. 71.3, p < 0.001). Multivariate analysis showed that diabetes mellitus was independently associated with HR > 70 bpm. Patients with resting HR > 70 bpm had significantly more frequent angina episodes (p < 0.001), were less satisfied with treatment (p < 0.001), and had a lower quality of life (p < 0.001). Conclusion: The baseline data of this study showed that patients with CAD and COPD present inadequate HR control and frequent angina episodes. Apart from the special characteristics of these patients related to COPD management, underuse of BB therapy largely contributes to the inadequate control of HR. Patients with HR > 70 bpm had significantly worse quality of life.

INTRODUCTION:Conduction of national surveys is needed to depict temporal trends in the risk profile, type of implemented treatment strategy and outcome of patients with acute coronary syndromes (ACS). The TARGET study is a multicenter, observational study that aimed to evaluate the epidemiological characteristics, management pattern and outcome of ACS patients in Greece.METHODS:A total of 418 consecutive patients with ACS (44.7% STEMI, 34.2% NSTEMI, 21.1% unstable angina) from 17 centers (52.9% with catheterization facilities) were enrolled in the study (78.0% males, 63.9 ± 12.9 years).RESULTS:Overall, 67.9% of the patients had hypertension, 27.5% were diabetics and 57.4% had dyslipidemia. Thrombolytic therapy (60.7% tenecteplase, 38.2% reteplase) was administered in 22.7% of the study population, while invasive management was performed in 40.2% of patients (27.0% PCI and 1.0% CABG) during the index hospitalization. In-hospital all-cause mortality was 1.9%, with 12.2% of patients experiencing adverse clinical events. Evidence-based medications were prescribed to the majority of enrolled patients during hospitalization and upon discharge (97% and 94% received aspirin, 93% and 84% clopidogrel, 87% and 86% beta-blockers, 96% and 93% statins, respectively).CONCLUSION:The prevalence of modifiable risk factors exhibits an increasing trend among ACS patients in Greece. The prescription pattern of evidence-based medications has improved considerably, while there remains considerable room for improvement in expanding the implementation of invasive management in realworld clinical practice.

Abstract We present a case of an acute myocardial infarction with ST segment elevation in a patient with a mechanical aortic valve prosthesis who had discontinued anticoagulant therapy. We performed a primary coronary intervention procedure, including thrombus aspiration as well as plain balloon angioplasty (low atmospheres), in order to restore coronary flow in left anterior descending artery as soon as possible. Review of the literature suggests that in such cases the diagnosis of the embolic origin of the acute coronary syndrome is assumed and can never been proved definitely. Thrombus aspiration must be included in the therapeutic strategy of these patients.

T he assessment of right heart function remains difficult, despite rapid technological developments in echocardiography.1 This is due to the fact that there are limitations to each of the echocardiographic techniques currently used in clinical and academic practice. The volume calculation and estimation of ejection fraction are not ideal for the clinical assessment of right ventricular (RV) function. However, regional myocardial wall motion detection by M-mode and tissue Doppler velocities are probably the most useful methods in clinical practice. Onedimensional (1D) and two-dimensional (2D) strain, velocity vector imaging, and four-dimensional (4D) echocardiography need further evaluation before they can be considered as routine investigations. Global attention needs to be paid to a very important, but neglected entity, the right ventricle, whose functional performance has been shown to predict exercise tolerance and outcome in a number of syndromes.2

Inflammation plays a key role in the pathogenesis of acute coronary syndromes (ACS). In this context we assessed neutrophil count as a predictor of major in‐hospital events in patients admitted for a non‐ST‐segment elevation (NSTE) ACS.

Aim: Το compare echocardiographic left ventricular (LV) long axis function and single photon emission computed tomography (SPECT) thallium-201 scintigraphy for the prediction of recovery of LV dyssynergies after revascularization. Methods: Thirty patients with a history of previous myocardial infarction and LV dysfunction underwent a transthoracic echocardiographic study before and after successful revascularization (101±14 days), in order to evaluate post-revascularization recovery of asynergic myocardial walls. In these patients and in 25 ageand sex-matched healthy subjects, an additional study during dobutamine infusion was also performed. All subjects also underwent SPECT thallium-201 scintigraphy. Prior and during dobutamine infusion the LV systolic atrioventricular (AV) plane displacement was recorded from the apical four and two chamber views, by M-Mode, at four LV sites, corresponding to the septal, lateral, anterior and inferior walls. Results: Healthy subjects showed a significant increase in AV displacement at all LV sites during dobutamine infusion (p 0.05). Selecting a maximum LV systolic AV displacement increase of >2 mm, the method proved to have a sensitivity of 91%, specificity of 83%, positive predictive value of 88% and negative predictive value of 87%. When SPECT thallium scans were used, the above indices were 86%, 65%, 74% and 79% respectively. Conclusion: The assessment of LV long axis function with the measurement of left systolic AV plane displacement during dobutamine infusion constitutes a simple and accurate method, better than SPECT thalium images, for the prediction of recovery of LV asynergy after revascularization. Euroclinic Hospital, Athens, Greece Nikaia General Hospital, Piraeus, Greece 1 Department of Cardiology, Evagelismos Hospital, Athens, Greece 2 Department of Cardiology, University of Athens, Attikon Hospital, Athens, Greece Agia Varvara Hospital, Athens, Greece

The assessment of the left and right ventricular long axis function by Doppler echocardiography was started many years ago with the use of M-mode. Two-dimensional echocardiography was subsequently used to study the longitudinal function of the left ventricle. The studies of that era led to useful conclusions. However, tissue Doppler imaging, a relatively new echocardiographic technique, recently became the first choice for such an assessment. Moreover, the advances of tissue tracking and strain rate also have an important contribution. New studies were conducted and new data derived for left and right ventricular function in various cardiac diseases. Τhe aim of this review was to present the accumulated knowledge of the Doppler echocardiography study of the left ventricular long axis function and the relevant clinical implications.

Sustained ventricular tachycardia during dobutamine stress echocardiography is a rare complication of dobutamine stress echocardiography. It may be related to reduced left ventricular function and prior myocardial infarction but cannot be used as a sensitive or specific sign for myocardial ischemia. The clinical significance of dobutamine stress echocardiography-induced sustained ventricular tachycardia is uncertain, and this condition probably does not represent an adverse prognostic sign.

A b s t r A c t Several electrocardiographic (ECG) changes have been described with pneumothorax, most often left-sided. We present a case of spontaneous right-sided pneumothorax, presenting with an ECG suggesting an old myocardial infarction. A chest X-ray confirmed the diagnosis of pneumothorax, while an echocardiogram and serial cardiac enzyme testing excluded myocardial infarction. ECG changes returned to normal after chest tube insertion. Physicians should be familiar with the ECG changes that can be caused by pneumothorax in order to avoid diagnostic and therapeutic pitfalls. A variety of ECG changes have been reported with spontaneous pneumothorax. They range from ST segment elevation suggestive of acute myocardial infarction to diminution of R wave in the precordial leads and inversion of precordial T waves. The major characteristic of these ECG changes is the fact that they return to normal with the resolution of pneumothorax. In most cases it is a left-sided pneumothorax affecting the ECG [1,2]. We present a case of spontaneous right-sided pneumothorax with ECG changes suggestive of an old myocardial infarction.

Intracardiac echocardiography (ICE) has been used as an adjunctive tool during electrophysiological procedures, mainly to increase the safety of transseptal puncture. We present the case of a young patient with a left-lateral bypass tract and atrial septal aneurysm, in whom ICE delineated the underlying anatomy, excluded the presence of thrombus and facilitated access to the left atrium through a small atrial septal defect, avoiding the risk of needle puncture for interatrial septal crossing.

Study of Left Ventricular Long Axis Function in Patients with Hypertensive Response to Exercise

We present a case of a thrombus formation within the left ventricle of a patient with a normal heart, who had previously been receiving high doses of erythropoietin for an inappropriately prolonged period.