Carotid Sinus Research Articles

SAT314 Bilateral Sporadic Carotid Paraganglioma As A Rare Cause Of Syncope

Abstract Disclosure: A.G. Olafimihan: None. U.A. Ogar: None. I. Asemota: None. E. Krishnaraju: None. A. Okafor: None. Introduction: Carotid body tumors (CBT) are rare, mostly non-secretory skull-based neuroendocrine tumors originating from the parasympathetic ganglia. They are the most common (60%) paragangliomas of the head and neck. Bilaterality is seen in 5% of patients with sporadic CBT. CBT mainly presents as an asymptomatic neck mass. Seldomly, it compresses the carotid sinus, inducing bradycardia and hypotension, and presenting with recurrent syncope. Case presentation: A 70-year-old Eritrean woman visiting the US with a history of myasthenia gravis status post thymectomy on pyridostigmine presented following an episode of presyncope with five similar episodes in the past year. She described it as sudden onset lightheadedness that resolves with sitting and sometimes results in syncope. She had no palpitations, headaches, or sweating.Her admitting vital signs were significant for bradycardia (48bpm) with hypotension (112/54mmhg). A physical exam revealed mobile, mildly tender, palpable neck masses bilaterally, with reproducible worsening bradycardia on palpation of the masses. ECG was unremarkable except for sinus bradycardia. A CT angiogram head and neck with contrast showed multiple hyper-enhancing lesions (two on the right, one on the left; largest = 1.6 x 1.0 cm) at the junction of bilateral carotid bulbs suggestive of multiple paragangliomas. An MRI of the neck re-demonstrated these lesions with the classical ‘salt and pepper’ appearance. CT of the brain, chest, abdomen and pelvis were negative for metastatic lesions. Biochemical testing including plasma metanephrines, catecholamines and dopamine levels was normal, suggesting nonfunctional tumors. Genetic testing was negative for mutations associated with paragangliomas. She did not have more episodes during her three-day admission but remained bradycardic with uneventful telemetry. She was counseled to avoid sudden neck movement and neck pressure. She was discharged with multidisciplinary (endocrinology, neurology, vascular surgery, and ENT surgery) outpatient follow-up. Over the five months post-discharge, she had only two mild symptomatic episodes. Following multi-specialist deliberations at the tumor board, including a risk-benefit assessment of a surgical excision, and extensive discussions with our patient and her family, the decision to hold off surgery was made. Surgical intervention was associated with possible vagal nerve injury, and high aspiration risk given her comorbid myasthenia gravis. Her conservative management plan included a cardiology work-up for symptom-directed therapy with a pacemaker placement. Conclusion: Recurrent syncope is an uncommon presentation of carotid body tumors requiring workup to rule out functionality, genetic mutations, and metastases. Management involves a multi-disciplinary approach and individual risk-benefit assessment of treatment options. Presentation: Saturday, June 17, 2023

Manejo diagnóstico del síncope en urgencias

Syncope is a very common cause for consultation in emergency departments (EDs). Therefore, identifying patients who present criteria for considering it to be high risk is fundamental for proper management. Most of the causes are benign, with neurally mediated syncope and orthostatic hypotension representing the largest proportion of cases seen in EDs. Syncope due to cardiac causes, generally secondary to arrhythmias and aortic stenosis, is more common in the older adult population. In an assessment, it must be confirmed if there was a transient loss of consciousness, if its origin is syncopal or not, and consider if there is an etiological diagnosis. A physical examination and ECG must be performed on all patients. Based on the results and the case history, other additional tests can be proposed, such as a blood test, echocardiogram, carotid sinus massage, or prolonged monitoring.

Vagal Maneuvers in Treating Acute Supraventricular Tachycardia with Narrow QRS

Abstract Treatment of supraventricular tachycardia with narrow QRS complexes (SVT) includes different therapeutic strategies such as: cardioversion, drug therapy or vagal maneuvers, depending on the patient’s condition, especially if they are hemodynamically stable or unstable. Vagal maneuvers are used to treat SVT during the acute presentation, if the patient is stable. They are recommended by the 2019 European Society of Cardiology guidelines for management of SVT with narrow QRS complexes. These include the Valsalva maneuver (enhanced or not) and carotid sinus massage. They have multiple advantages: they do not require medical equipment, can be performed anywhere (at the bedside or in an outpatient setting), have minimal risk and high effectiveness (19-54 % rate of success).

The internal carotid artery in the ontogenesis of selected representatives of the Cervidae family in Poland

In Poland, the environment occurs with the red deer, fallow deer, Eurasian elk and roe deer. Among the ruminants, changes occurring during ontogeny in the arterial system of the head, involving obliteration of the extracranial segment of the internal carotid artery. The aim of this study was to describe the presence and course of the internal carotid artery and indicate the timing of changes in the vascular system of the head associated with the process of obliteration of this vessel. The study was conducted on 146 representatives of the Cervidae family: red deer, fallow deer and roe deer This study showed the presence of a fully preserved internal carotid artery in fetuses and young animals up to the age of about two years. In animals of about 2.5 years of age, only the initial fragment of the internal carotid artery emerging from the carotid sinus and a short fragment directly through the rostral epidural rete mirabile were preserved. In adult animals older than three years the extracranial part of this artery was obliterated.

Multimodality imaging of transient perivascular inflammation of carotid artery (TIPIC) syndrome: a case report

BackgroundTransient Perivascular Inflammation of Carotid artery syndrome is a rare clinicoradiological entity characterized by inflammation of the carotid artery wall with surrounding perivascular inflammatory changes. This is a self-limiting condition and necessitates awareness and high degree of suspicion to differentiate from other serious pathologies involving the carotid artery.Case presentationA middle aged asian male patient presented with acute onset of intense pain in the right lateral aspect of neck. Ultrasonography and Magnetic Resonance Imaging showed wall thickening of the common carotid artery and carotid bulb with surrounding inflammation in the perivascular soft tissues. He was treated with brief course of oral anti-inflammatory medications. The patient’s symptoms improved and imaging findings resolved in 2 weeks.ConclusionsBeing infrequently encountered in clinical practice, recognition of transient perivascular inflammation of carotid artery syndrome by the physician is of prime importance. Prompt radiological investigation and follow-up imaging are crucial for accurate diagnosis, thereby leading to appropriate treatment.

Effectiveness of the oral Clonidine as a pre-anesthetic medicine for thyroidectomy surgery; A randomized clinical trial.

Hemodynamic disturbance is a common problem in patients undergoing thyroid surgery. It may be due to episodic increases in thyroid hormones (thyroid storm) or stimulation of the carotid sinus baroreflex. The aim of the present study was to investigate effectiveness of the pre-operative oral Clonidine on reducing these hemodynamic changes during total thyroidectomy surgery. In a prospective, randomized, double-blind study, 80 patients scheduled for elective total thyroidectomy were randomized to receive either 0.2 mg Clonidine (n=40) or a matched placebo (n=40) orally sixty minutes before entering the operating room. Hemodynamic variables, the duration of surgery, estimated amount of blood loss and the dose of administered remifentanil were recorded for further analysis. Oral Clonidine was found to be significantly better in maintaining stable hemodynamics compared to the control group. Also, In the Clonidine group, the estimated amount of blood loss (110.4±10 ml vs. 182.2±11.4 mL, P=0.04), duration of the surgery (78.26±55.2 min vs. 105.16±61.75 min, P=0.027) and administered dose of remifentanil (26.67±6.6 μg vs. 216.2±14.8 μg, P=0.01) were also significantly lower than the control group. Pre-operative administration of 0.2 mg oral Clonidine in patients undergoing total thyroidectomy results in improved perioperative hemodynamic stability and reduced response to perioperative stress.

Cardiovascular Disorders and Falls Among Older Adults: A Systematic Review and Meta-Analysis.

Falls are a common cause of injury, hospitalization, functional decline, and residential care admission among older adults. Cardiovascular disorders are recognized risk factors for falls. This systematic review assesses the association between cardiovascular disorders and falls in older adults. Systematic searches were conducted on MEDLINE and Embase, encompassing all literature published prior to December 31, 2022. Included studies addressed persons aged 50 years and older, and assessed the association between cardiovascular disorders and falls or the efficacy of cardiovascular-based interventions to reduce falls. Two reviewers independently extracted data and assessed study quality utilizing a modified Newcastle-Ottawa scale for observational studies, and the Cochrane Risk of Bias 2 tool for interventional studies. A systematic narrative analysis of all cardiovascular outcomes, and meta-analyses of unadjusted odds ratios (ORs) were performed. One hundred and eighty-four studies were included: 181 observational and 3 interventional. Several cardiovascular disorders, including stroke, coronary artery disease, valvular heart disease, arterial stiffness, arrhythmia, orthostatic hypotension, and carotid sinus hypersensitivity, were consistently associated with falls. In meta-analysis of unadjusted ORs, the largest positive pooled associations with falls during a 12-month reporting interval were for stroke (OR: 1.90, 95% confidence interval [CI]: 1.70-2.11), peripheral arterial disease (OR: 1.82, 95% CI: 1.12-2.95), atrial fibrillation (OR: 1.52, 95% CI: 1.27-1.82), and orthostatic hypotension (OR: 1.39, 95% CI: 1.18-1.64). Several cardiovascular disorders are associated with falls. These results suggest the need to incorporate cardiovascular assessments for patients with falls. This review informed the cardiovascular recommendations in the new World Guidelines for falls in older adults.Clinical Trials Registration Number: CRD42021272245.

Acute effects of empagliflozin on open-loop baroreflex function and urinary glucose excretion in rats with chronic myocardial infarction

Sodium–glucose cotransporter 2 (SGLT2) inhibitors have exerted cardioprotective effects in clinical trials, but underlying mechanisms are not fully understood. As mitigating sympathetic overactivity is of major clinical concern in the mechanisms of heart failure treatments, we examined the effects of modulation of glucose handling on baroreflex-mediated sympathetic nerve activity and arterial pressure regulations in rats with chronic myocardial infarction (n = 9). Repeated 11-min step input sequences were used for an open-loop analysis of the carotid sinus baroreflex. An SGLT2 inhibitor, empagliflozin, was intravenously administered (10 mg/kg) after the second sequence. Neither the baroreflex neural nor peripheral arc significantly changed during the last observation period (seventh and eighth sequences) compared with the baseline period although urinary glucose excretion increased from near 0 (0.0089 ± 0.0011 mg min−1 kg−1) to 1.91 ± 0.25 mg min−1 kg−1. Hence, empagliflozin does not acutely modulate the baroreflex regulations of sympathetic nerve activity and arterial pressure in this rat model of chronic myocardial infarction.

Histology and immunohistochemistry of the human carotid sinus nerve.

The carotid sinus nerve (CSN) is well known as mediating baroreflexes. However, studies of its detailed histological analysis are scant in the literature. Therefore, the current anatomical study sought to better elucidate the microanatomy of the CSN. Ten fresh frozen adult cadavers underwent dissection of the CSN. Then, it was harvested and submitted for histological and immunohistochemical staining. Specimens were all shown to be nerve fibers on histology and immunohistochemistry. We identified tyrosine hydroxylase positive fibers in all CSN specimens. These fibers were always found to be within the CSN and not on its surface i.e., epineurium. Based on our findings, the majority of fibers contained in the CSN are tyrosine positive in nature. Further studies are necessary to understand the true function of this autonomic nerve fibers.

Symptomatic carotid webs require aggressive intervention

ObjectiveCarotid web (CaWeb) is a rare form of fibromuscular dysplasia that can produce embolic stroke. Misdiagnosis of symptomatic CaWeb as “cryptogenic stroke” or “embolic stroke of unknown source” is common and can lead to recurrent, catastrophic neurologic events. Reports of CaWeb in the literature are scarce, and their natural history is poorly understood. Appropriate management remains controversial. MethodsCaWeb was defined as a single, shelf-like, linear projection in the posterolateral carotid bulb causing a filling defect on computed tomography angiography (CTA) or cerebral angiography. Cases of symptomatic CaWeb at a single institution with a high-volume stroke center were identified through collaborative evaluation by vascular neurologists and vascular surgeons. ResultsFifty-two patients with symptomatic CaWeb were identified during a 6-year period (2016-2022). Average age was 49 years (range, 29-73 years), 35 of 52 (67%) were African American, and 18 of 52 (35%) were African American women under age 50. Patients initially presented with stroke (47/52; 90%) or transient ischemic attack (5/52; 10%). Stenosis was <50% in 49 of 52 patients (94%) based on NASCET criteria, and 0 of 52 (0%) CaWebs were identified with carotid duplex. Definitive diagnosis was made by CTA examined in multiple planes or cerebral angiography examined in a lateral projection to adequately assess the posterolateral carotid bulb, where 52 of 52 (100%) of CaWebs were seen. Early in our institutional experience, 10 of 52 patients (19%) with symptomatic CaWeb were managed initially with dual antiplatelet and statin therapy or systemic anticoagulation; all suffered ipsilateral recurrent stroke at an average interval of 43 months (range, 1-89 months), and five were left with permanent deficits. Definitive treatment included carotid endarterectomy in 27 of 50 (56%) or carotid stenting in 23 of 50 (46%). Two strokes were irrecoverable, and intervention was deferred. Web-associated thrombus was observed in 20 of 50 (40%) on angiography or grossly upon carotid exploration. Average interval from initial stroke to intervention was 39 days. After an average follow-up of 38 months, there was no reported postintervention stroke or mortality. ConclusionsTo our knowledge, this is the largest single-institution analysis of symptomatic CaWeb yet reported. Our series demonstrates that carotid duplex is inadequate for diagnosis, and that medical management is unacceptable for symptomatic CaWeb. Recurrent stroke occurred in all patients managed early in our experience with medical therapy alone. We have since adopted an aggressive interventional approach in cases of symptomatic CaWeb, with no postoperative stroke reported over an average follow-up of 38 months. In younger patients presenting with cryptogenic stroke, especially African American women, detailed review of lateral cerebral angiography or multi-planar, fine-cut CTA images is required to accurately rule out or diagnose CaWeb and avoid recurrent neurologic events.

Heterogeneous Carotid Plaque Predicts Cardiovascular Events after Percutaneous Coronary Intervention.

The relationship between carotid artery ultrasound findings and clinical outcomes in patients who undergo percutaneous coronary intervention (PCI) has not been completely elucidated. This single-center retrospective study investigated 691 patients who underwent PCI and carotid ultrasound testing. Maximum carotid intima-media thickness (CIMT) was defined as the greatest CIMT at the maximally thick point among the common carotid artery, carotid bulb, and internal carotid artery. A carotid plaque was defined as vessel wall thickening with a CIMT ≥ 1.5 mm. The characteristics of carotid plaque (heterogeneity, calcification, or irregular/ulcerated surface) were evaluated visually. Patients were divided into those with and without heterogeneous carotid plaque (maximum CIMT ≥ 1.5 mm and heterogeneous texture). The endpoint was the incidence of a major adverse cardiovascular event (MACE) defined as a composite of cardiovascular (CV) death, myocardial infarction, and ischemic stroke. Among 691 patients, 309 were categorized as having a heterogeneous plaque. Patients with heterogeneous plaques were at a higher risk of MACE than those without (p=0.002). A heterogeneous plaque was independently associated with MACE after adjusting for covariates (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.01-2.90; p=0.046). Calcified or irregular/ulcerated plaques were correlated with a higher incidence of MACE, but both were not independently associated with MACE (HR, 1.35; 95% CI, 0.69-2.64, p=0.38 and HR, 0.98; 95% CI, 0.57-1.69; p=0.95, respectively). The presence of a heterogeneous carotid plaque in patients who underwent PCI predicted future CV events. These patients may require more aggressive medical therapy and careful follow-up.

The relationship between asymptomatic atherosclerosis and hepcidin-25 in chronic kidney disease patients.

The most common and lethal consequence of chronic kidney disease (CKD) is atherosclerotic cardiovascular disease. The persistent inflammation present in CKD increases hepcidin levels. Iron accumulates in the arterial wall in atherosclerosis. Hepcidin-25 was thought to accelerate the development of atherosclerotic plaques by blocking iron release from macrophages. Therefore, we sought to determine the relationship between hepcidin-25 and asymptomatic atherosclerosis in non-dialysis CKD patients. Investigate the relationship between hepcidin-25 and subclinical atherosclerosis in non-dialysis CKD patients. Cross-sectional SETTINGS: Outpatient clinic for urology and nephrology at a university hospital SUBJECTS AND METHODS: Participants above the age of 18 years included a group of healthy controls and a group of CKD patients who were not routinely maintained on hemodialysis. The latter group was further divided according to eGFR into CKD-3, CKD-4 and CKD-5 subgroups. We excluded patients with comorbidities, patients with chronic liver disease, and other conditions or habits. CBC, kidney function tests, and serum levels of hepcidin-25 (SH-25), TNF-α, IL-6, high-sensitivity C-reactive protein (hs-CRP), TC, TG, LDL-C and HDL-C were assessed. To measure carotid intima media thickness (CIMT) and determine presence of plaques, carotid ultrasonography was performed. The near or far walls of common carotid artery, bulb, and internal carotid artery were used to measure CIMT. SH-25 association and indicators of subclinical atherosclerosis. 128 participants, the control group (n=25) and the non-hemodialysis CKD patients (n=103) RESULTS: The CKD patients had significantly higher serum levels of markers of inflammation including IL-6, TNF-α, and hs-CRP (P<.001 for each) compared to the controls. There was a significantly higher level of TC, TG and LDL-C (P<.001 for each) and a lower level of HDL-C (P<.001) in the CDK patients compared to controls. SH-25 was considerably higher in all CKD subgroups, especially with progression of CKD. CIMT was increased in CKD patients especially CKD-4 and CKD-5 subgroups when compared to healthy participants (P<.001 for each). In the patient group, CIMT showed a positive correlation with SH-25, (r=.65 and P<.001), IL-6 (r=.65, P<.001), TNF-α (r=.71, P<.001), and hs-CRP (r=.52, P<.001). The ROC curve study showed that SH-25 (AUC=.86, P<.001), IL-6 (AUC=.83, P<.001), hs-CRP (AUC=.72, P<.001), TNF-α (AUC=.82, P<.001) were strong predictors of subclinical atherosclerosis in the CKD patients. SH-25 and CIMT had a positive relationship in CKD patients. The ROC curve showed that SH-25 is a reliable predictor of carotid atherosclerosis. Therefore, we suggest that SH-25 is a vital biomarker of asymptomatic atherosclerosis. Single-center.

Relation of forward and backward traveling pressure waves with subclinical carotid artery wall remodeling and central pulse pressure.

Central pulse pressure (PP) is the sum of forward and backward traveling pressure waves that have been associated with cardiovascular disease (CVD) risk. However, previous studies have reported differential findings regarding the importance of the forward versus the backward wave for CVD risk. Therefore, we sought to determine the degree to which the forward and backward pressure waves are associated with subclinical carotid artery wall remodeling and central PP in healthy adults. Using applanation tonometry, carotid pressure waveforms were acquired in 308 healthy individuals (aged 45 ± 17 years, range 19-80 years, 61% women), from which the time integral of the forward (PfTI) and backward (PbTI) pressure waves were derived via pressure-only wave separation analysis. Common carotid artery intima-media thickness (cIMT), a biomarker of subclinical CVD risk, was derived via B-mode ultrasonography measured ∼2 cm from the carotid bulb. Both PfTI (r = 0.31, P < 0.001) and PbTI (r = 0.40, P < 0.001) were correlated with cIMT. However, further analysis revealed that PbTI mediated the relation between PfTI and cIMT (proportion mediated = 156%, P < 0.001). The association between PbTI and cIMT remained after adjusting for age, sex, body mass index, blood glucose, low-density lipoprotein cholesterol, heart rate, brachial systolic pressure, and aortic stiffness (B = 0.02, 95% confidence interval = 0.01, 2.77, P < 0.001). Both PfTI (r = -0.58, P < 0.001) and PbTI (r = -0.50, P < 0.001) were correlated with central PP, however, PfTI fully mediated the association between PbTI and central PP (proportion mediated = 124%, P < 0.001). Although PfTI is correlated with higher central PP, it is PbTI that is directly associated with carotid artery wall remodeling.NEW & NOTEWORTHY The present study contributes to the growing body of evidence highlighting the physiological and clinical insight provided by the pulsatile hemodynamic components of central artery pulse pressure. The notable findings of this study are: 1) The reflected (backward) pressure wave is associated with carotid intima-media thickness independent of traditional cardiovascular risk factors, including systolic blood pressure and aortic stiffness. 2) The incident (forward) pressure wave, and not the reflected pressure wave, is associated with greater central pulse pressure.

Comparison of common carotid artery luminal diameter between adults with diabetes mellitus and healthy controls in North-eastern Nigeria

Background: Common carotid artery luminal diameter (CCALD) is used in epidemiological and interventional studies as biomarker of carotid atherosclerosis especially in subjects with DM. However, there are paucity of studies on the CCALD in subjects with DM in the study locality. Purpose: This study is aimed at evaluating the CCALD in adults with DM differ from those of healthy controls Methodology: Common carotid artery luminal diameters (CCALD) of 82 adult subjects with DM and 144 healthy controls were evaluated using a high-resolution ultrasound machine (Venue 50) equipped with electronic callipers and a linear array, high-frequency transducer (7-12 mHz). Measurements were taken at a point 1 cm distal to the carotid bulb. Results: The overall mean CCALD was 6.12±1.47 mm and 5.88±0.77 mm for subjects with DM and healthy controls, respectively. The mean CCALD value is higher in subjects with DM compared to those of healthy controls though; there was no statistically significant difference in CCALD between the two groups. There were significant positive correlations between CCALD and age in male subjects with DM (r=0.488) while weak negative correlation exists in females (r=-0.073).Furthermore, weak negative correlation between CCALD and age among healthy controls (r=-0.117 and -0.020 for males and females, respectively). Conclusion: The overall mean CCALD value in subjects with DM is higher than those of healthy control. The mean CCALD value is positively and significantly related to age in only male subjects with DM.

Cardioneuroablation for carotid sinus syndrome mediated by complete atrioventricular block.

Carotid sinus syndrome (CSS) is a rare condition leading to recurrent syncope. Permanent pacemaker implantation is the mainstay treatment of cardioinhibitory CSS. In this report, we present a CSS patient with reproducible atrioventricular block during carotid massage, who was treated with cardioneuroablation.

Targeted delivery of therapeutic agents in a healthy and stenosed patient-specific carotid artery using an external magnetic field

In Magnetic Drug Targeting (MDT), an alternative and highly efficient technique to traditional drug delivery methods, therapeutic agents labeled with magnetic particles are transported to a target region using an external magnetic field. A high concentration of agents in the target tissue and their non-dispersion in the body increases treatment efficiency. In this study, targeted delivery of endothelial cells containing magnetic particles in a healthy and stenosed patient-specific carotid artery was studied. The Eulerian-Lagrangian approach was adapted to track the motion of particles and solve fluid equations. The effect of many internal parameters such as plaque morphology (occlusion percentage and the chord length of stenosis) and external parameters such as the strength and the position of the magnetic source, injection time, and the mass of magnetic particles inside each cell on the capture efficiency (CE) of cells was investigated. Results reveal that increasing the mass of magnetic particles in each cell and magnetic field strength enhances the capture efficiency of cells in the target region. Also, shifting the magnetic source location from position 1 (before the carotid sinus) to position 3 (after the carotid sinus) can increase and decrease the number of absorbed cells in the target region and CCA, respectively, both of which are desirable. Investigation of the injection time shows that the CE of cells when injecting in the systole and diastole is approximately the same as their CE when injected in a whole cardiac cycle. For a stenosed carotid artery, the percentage of occlusion is directly related to the CE of cells in the target region. Also, the chord length of stenosis has a direct and inverse relationship with the number of absorbed cells on the plaque surface and in the target region, respectively. Therefore, magnetic particles with higher magnetism or stronger magnetic fields are recommended for the stenosed carotid artery with a more severe occlusion percentage or a longer chord length.

Predictors of hemodynamic instability during and persistent after carotid artery stenting

ObjectivesThe risk factors for post-carotid artery stenting severe hemodynamic instability remain elusive. This study aimed to identify the predictors of severe hemodynamic instability during and persisted after carotid artery stenting. Materials and methodsConsecutive patients who underwent carotid artery stenting for extracranial carotid artery stenosis at a single-center between September 2018 and July 2021 were retrospectively assessed. The predictive factors of severe hemodynamic instability intraoperation and post-operation were analyzed. ResultsAmong the 139 patients included, 63 experienced severe hemodynamic instability, with 45 and 18 cases occurring intra and postoperatively, respectively. Persistent was observed in 21 patients. Smoke exposure (odds ratio [OR], 2.38; p=0.039), carotid bifurcation stenosis (OR, 0.91; p=0.018), and large-diameter balloon (>4 mm) dilatation (OR, 11.95; p<0.001) were identified as independent risk factors for hemodynamic instability at any stage of carotid artery stenting. Intraoperatively, large-diameter balloon (>4 mm) dilatation was associated with an increased risk of hemodynamic instability occurrence (OR, 4.67; p=0.01), whereas general anesthesia (OR, 0.19; p=0.001) and a longer distance from the stenosis to the carotid bifurcation (OR, 0.89; p=0.01) were negatively associated with hemodynamic instability. Furthermore, smoking exposure (OR, 3.73; p=0.03), large diameter balloon dilatation (OR, 6.12; p=0.032), distance from stenosis to bifurcation (OR, 0.85; p=0.047) and long-stent (40 mm) implantation (OR, 0.84 [95% confidence interval, 0.74–0.95]; p=0.007) could independently predict persistent hemodynamic instability. ConclusionPatients with a smoking history, lesions near the carotid bulb, or dilatation using a large-diameter balloon were most likely to suffer severe hemodynamic instability. General anesthesia can protect against severe hemodynamic instability only intraoperatively. Long-term stent implantation may reduce persistent hemodynamic instability.

Sex Related Differences in Electrocardiography.

Since its implementation into the clinical medicine by Willem Einthoven electrocardiography had become one of crucial diagnostic method in cardiology. In spite of this fact effects of gender differences on parameters of electrocardiographic recordings started to be studied only recently. Sex related differences in physiological ECG are only minimal in childhood but there are developing during adolescence reflecting rapidly evolving differences particularly in hormonal secretion and activity of an autonomic nervous system. The heart rate is approximately 7 % higher in women than in men, PQ and QRS intervals are longer in men while QT interval is longer in women. The ST segment in females is flatter but generally the sex-related differences in ST-T waveform patterns are relatively very small with higher level of ST segment and taller T wave in men. The effects of sex-related differences, including sex hormones, on cardiac cell injury and death and their influence in determining rhythmogenesis and action potential configuration and conduction play an important role in clinics. Women have a higher prevalence of sick sinus syndrome, inappropriate sinus tachycardia, atrioventricular nodal reentry tachycardia, idiopathic right ventricular tachycardia, and arrhythmic events in the long QT syndrome. In contrast, men have a higher prevalence of atrioventricular block, carotid sinus syndrome, atrial fibrillation, supraventricular tachycardia due to accessory pathways, Wolff-Parkinson-White syndrome, reentrant ventricular tachycardia, ventricular fibrillation and sudden death, and the Brugada syndrome.

Tortuosity and Proximal-Specific Hemodynamics Associated with Plaque Location in the Carotid Bulb Stenosis

Background: Atherosclerotic plaque locations in the carotid bulb increasingly have been found to be associated with patterns of ischemic lesions and plaque progression. However, the occurrence of carotid bulb plaque is a complex process. We aimed to investigate plaque characteristics and geometric and hemodynamic parameters among patients with body and apical plaques of the carotid bulb and to identify the mechanism of bulb plaque formation and location. Methods: Consecutive patients with single carotid bulb stenosis (50–99%) were enrolled retrospectively. Patients were divided into body and apical plaque groups based on plaque location. Plaque location and characteristics were identified and measured on high-resolution vessel wall magnetic resonance imaging. Geometric parameters were derived from time-of-flight magnetic resonance imaging. Computational fluid dynamics simulations were performed to quantify wall shear stress (WSS) and four associated WSS-based metrics on the plaque side, on the non-plaque side, and in different parts of the lesion. Plaque characteristics and geometric and hemodynamic parameters were compared, and their associations with the plaque location were determined. Results: Seventy patients were recruited (41 body plaques and 29 apical plaques). WSS_plaque values were lower than WSS_non-plaque values for all plaques (median [interquartile range], 12.59 [9.83–22.14] vs. 17.27 [11.63–27.63] Pa, p = 0.001). In a multivariate binary logistic regression, the tortuosity of the stenosed region, the magnitudes of the mean relative residence time, and the minimum transverse WSS in the proximal part of the lesion were the key factors independently associated with plaque location (p = 0.022, 0.013, and 0.012, respectively). Conclusions: Plaque formation was associated with the local flow pattern, and the tortuosity and proximal-specific hemodynamics were significantly associated with plaque location in the carotid bulb.

Comparison of the effectiveness of various valsalva maneuvers in the management of stable narrow and wide QRS complex tachycardia in the emergency department

Purpose: Narrow and wide QRS complex tachycardias are among the causes of arrhythmia in patients frequently admitted to the emergency department (ED). The first recommended step in the management of patients with a stable narrow and wide QRS tachycardia is a vagal maneuver. Althougah there are many maneuvers that can provide vagal stimulation, the most effective vagal maneuver is still unknown. This study aims at determining the most effective vagal maneuver by comparing the four most commonly used maneuvers.&#x0D; Materials and methods: One hundred and thirty-two patients were included in this study; they were randomly and equally distributed into four groups. Carotid sinus massage (CSM) was applied to the first group, the REVERT method was applied to the second group (a 10-cc injector was used), a modified REVERT method was applied to the third group (a 60-cc injector was used), and the abeslang (wooden tongue depressor) method was applied to the fourth group. During these four applications, the patients’ vital signs were monitored, and preparations were made for any emergency.&#x0D; Results: Of the 132 patients included in the study, 61 (46.2%) were males, and 71 (53.8%) were females. The average age of the patients was 56.3 years. One hundred and twenty-six had narrow QRS tachycardias, and 6 had stable wide QRS tachycardias. The patients were randomly distributed into 4 groups. In the 1st group, 1 patient (3%) returned to a normal rhythm with the CSM method. In the 2nd group, 3 patients (9.1%) returned to a normal rhythm with the REVERT method. Nine patients (27.3%) in the 3rd group returned to a normal rhythm with the modified REVERT method. 6 patients (18.2%) in the 4th group returned to normal rhythm with the abeslang method. None of the stable wide QRS tachycardias responded to vagal stimulation methods.&#x0D; Conclusion: The modified REVERT and abeslang methods are preferred primarily in patients entering the ED with the complaint of a stable narrow or wide QRS tachycardia in the case that a vagal maneuver is to be applied. On the other hand, a vagal maneuver is not effective in the management of a stable wide QRS tachycardia.