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Twiddler's syndrome, a rare but potentially lethal complication of cardiac pacemaker treatment, is generally diagnosed within the first year of implantation. It is characterized by device malfunction due to dislodgement of cardiac leads resulting from some form of manipulation by the patient. In this report we present a patient who was diagnosed Twiddler's syndrome within the initial 48 h of implantation of permanent pacemaker. In our case, passive fixation of ventricular lead perpetuated this situation and subsequent active fixation prevented any recurrence. Active fixations fixations of device leads are very much essential to prevent this catastrophic complication.

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Background: Primary percutaneous coronary intervention (PCI) has been shown to be an effective therapy for patients with acute myocardial infarction (MI). Glycoprotein (GP) IIb/IIIa receptor blockers reduce thrombotic complications in patients undergoing PCI. Most available data relate to Reopro, which has been registered for this indication. GP IIb/IIIa reduce unfavorable outcome in U/A and non ST-elevation myocardial infarction (STEMI) patients. Only few studies focused on high dose Aggrastat for STEMI patients in the emergency department (ED) before PCI. The aim is to increase the patency during the time awaiting coronary angioplasty in patients with acute MI. Objectives: To study the effect of upfront high bolus dose (HDR) of tirofiban on the extent of residual ST segment deviation 1 hour after primary PCI and the incidence of TIMI 3 flow of the infarct-related artery (IRA). Materials and Methods: A randomized, open label, single center study in the ED. A total of 90 patients with acute ST-elevation MI, diagnosed clinically by ECG criteria (ST segment elevation of >2 mm in two adjacent ECG leads), and with an expectation that a patient will undergo primary PCI. Patients were aged 21-85 years and all received heparin 5000 u, aspirin 160 mg, and Plavix 600 mg. Patients were divided in two groups (group I: triofiban high bolus vs group II: Reopro) with 45 patients in each group. In group I, high bolus triofiban 25 mcg/kg over 3 min was started in the ED with maintenance infusion of 0.15 mcg/ kg/min continued for 12 hours and transferred to cath lab for PCI. Patients in group II were transferred to cath lab, where a standard dose of Reopro was given with a bolus of 0.25 mcg/kg and maintenance infusion of 0.125 mcg/kg/min over 12 hours. Results: ST segment resolution and TIMI flow were evaluated in both groups before and after PCI. Thirty-five patients (78%) enrolled in group I and 29 patients (64%) in group II had resolution of ST segment (P-value 0.24). Twenty-one patients (47% group I) vs 23 patients (51% group II) with P-value 0.83 achieved TIMI 0 flow. Twenty-four patients (53% group I) compared with 22 patients (49% group II) with P-value 0.83 had TIMI 1 to 3 flow before PCI. TIMI 3 flow was achieved in 40 patients (89% group I) compared with 38 patients (84% group II) with P-value 0.76. Conclusion: In this study there was a trend toward better ST segment resolution and patency of IRA (i.e., improved TIMI flow) in patients given high bolus dose Aggrastat in the ED. Larger studies are needed to confirm this finding.

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One of the rarest congenital heart diseases that results from a defect between the main pulmonary artery and the proximal aorta is named aortopulmonary window (APW). Such abnormality could be isolated, but in fifty percent of patients may be associated with other cardiac abnormalities, including arch abnormalities, specifically coarctation of the aorta, interrupted aortic arch, tetralogy of fallot, and atrial septal defect (ASD). Surgical closure or catheter-delivered devices is recommended in all patients with APW and should be performed after diagnosis as soon as possible to prevent irreversible pulmonary vascular disease. In the current era, early mortality following repair of simple APW is low and depends on the presence of associated lesions, especially interrupted aortic arch. We report an 8-month-old boy with APW who was referred to our center by respiratory symptoms and heart murmurs.

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Objectives: Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic renal failure (CRF). This study attempts to identify the factors responsible for atherosclerosis in CRF patients using carotid artery intima media thickness (CAIMT) as a surrogate marker of atherosclerosis. Materials and Methods: CAIMT was measured by high-resolution B-mode ultrasonography in 100 CRF patients and 50 age- and sex-matched healthy controls. Data were analyzed by software SPSS (17 ^th version) for Windows. Results: CRF patients had a significantly higher CAIMT (1026.83 ± 17.19 micron, mean ± SE, P < 0.001) than age- and sex-matched healthy controls (722.46 ± 7.61 micron). There was inverse correlation between CAIMT and glomerular filtration rate (GFR) (P < 0.001) independent of traditional risk factors. There was also significant positive correlation between CAIMT and traditional risk factors of atherosclerosis. Ischemic heart disease (IHD) also showed positive correlation with CAIMT (P = 0.007) and inverse correlation with GFR (P = 0.005). Conclusions: There is high prevalence of atherosclerosis in CRF patients. CAIMT can be used to detect and predict future incidence of IHD in CRF patients.

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The middle aortic syndrome (MAS) is a rare condition characterized by diffuse narrowing of the descending thoracic aorta, abdominal aorta, or both. It can be congenital or acquired due to several conditions. We report an 8-year-old girl who developed middle aortic syndrome due to Takayasu arteritis.

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Takotsubo cardiomyopathy (TC) is a rare and usually physical or emotional stress-induced clinical disorder characterized by transient left ventricular dysfunction and apical segment ballooning. Much is still unknown regarding risk factors and clinical relationships. Recently, an association between TC and malignancies has been proposed. We present a case of lung adenocarcinoma whose initial hospital admission was due to TC. We contribute this case report to the growing set of literature on the association between TC and malignancies.

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We present a case of a young male with severe pulmonary stenosis, hypoplastic right ventricle, and atrial septal defect. Acute embolic myocardial infarction, followed by cardiac arrest, occurred during hospitalization after Glenn operation. The therapeutic challenges are discussed. Insufficient anticoagulation therapy during the postoperative period was a possible contributing factor leading to embolic myocardial infarction.

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Introduction: Enlarged left atrium predicts outcomes in patients with heart failure, atrial fibrillation and stroke. Left atrial volume especially when corrected for body size, is a more accurate representation of true LA size. Aims and Objectives: To study left atrial volume index in elderly patients with left ventricle anterior infarction and correlate LAVi with left ventricle ejection fraction and transmitral Doppler flow. Materials and Methods: Control group consisted of 25 healthy elderly subjects Study group consisted of age and sex matched patients with LV anterior infarction with history of characteristic ischaemic chest pain. Patients with valve lesions, large shunts and rythum disturbances were excluded. On transthoracic echocardiography biplane method of disks was used to calculate LA volume. LAVi was calculated by dividing LA volume by body surface area of subjects. Observation and Results: LAVi was significantly raised in elderly patients who suffered from AMI (P<0.005). We also found significant negative correlation of LAVi with LVEF, E wave peak velocity and deacceleration time. Conclusion: Patients with advanced left venticular systolic and diastolic dysfunction had a significantly larger LAVi than healthy subjects. LAVi is useful for risk stratification and for guiding therapy in such patients.

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Gastrointestinal complications after open-heart surgery are rare but may increase mortality rate significantly. We are presenting a rare complication of liver laceration after coronary bypass operation. The patient is a 57-year-old man who underwent urgent Coronary Artery Bypass Grafting operation (CABG). Liver laceration and free intra-peritoneal hemorrhage was discovered to be the result of chest tubes insertion, and resulted in drop of hemoglobin and hemodynamic instability. The hemorrhage was surgically controlled, and the patient made full recovery and was sent home. This case report emphasizes that when bleeding of unknown origin occurs after cardiac surgery, intra-abdominal bleeding should be considered.

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