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PP-373 EXCISION OF RECURRENT RA MYXOMA AND RECONSTRUCTION OF RA & SVC WITH BOVINE PERICARDIUM
S220
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
Methods: She complained from fatigue and dyspnea (NYHA III-IV FC), edema of the legs, ECG – LBBB, sinusu rhythm. Echocardiography confrmed the restrictive cardiomyopathy with dyastolic dysfunction, relatively preserved ejection fraction of both ventricles. The simultaneous left and right heart catheterization, with left and right ventriculography during 2009 in the National Heart Hospital diagnosed showed no changes in the coronary anatomy, with significant right and left ventricular hypertrophy. Results: During previous hospitalizations connective tissue disease was rejected, with negative laboratory results for antiphospholipid antibodies, two times negative subcutaneous biopsy for amyloidosis, which was suspected due to the typical clinical findings. After the hospitalization in our clinic besides the NYHA III-IV FC heart insufficeincy, later compensated hypopotassiemia was confrimed. After the ezplaining the risks of the procedure, in order to achieve exact diagnose and confirm or reject the suspected amyloidosis, the patient was proposed an ednomyocardial biopsy, which was made in our clinic. Conclusions: On 04.02.2011 after right heart catheterization, three samples from the right ventricle myocardium were taken and were sent to hystologic analysis, while the procedure itself passed without serious complications. The results of the hystologic analysis showed isolated, type AA cardiac amyloidosis, which is a very rare finding. The patient was feeling relatively well with medical therapy and waits for the suitable donor to receive heart transplantation. PP-371 RECIPROCAL ST SEGMENT CHANGES IN ACUTE INFERIOR MYOCARDIAL INFARCTION: CLINICAL, HEMODYNAMIC AND ANGIOGRAPHIC IMPLICATIONS M.A. Shehata1 , H.A. Effat3 , H.A. El Atroush2 . Critical Care Medicine, Cairo University, Cairo, Egypt Objective: To investigate the clinical significance of reciprocal ST segment depression on the presenting electrocardiogram in patients with acute inferior myocardial infarction. Design and Setting: A prospective, randomized, controlled single center study done in the critical care department, Cairo university Hospital. Subjects: Forty consecutive patients with acute inferior myocardial infarction were enrolled in this study divided into two groups, 20 patients with reciprocal ST depression (Group I) and 20 patients without such depression (Group II). Interventions: All patients were investigated with serial ECG, cardiac biomarkers, echocardiography and coronary angiography. Results: There was no significant differences in the proportion of coronary disease risk factors in patients in group I, versus those in group II. Patients in group I had significant higher degree ST elevation (in inf. Leads) than patients in group II, higher levels of peak total CPK and CKMB was also seen. In addition patients in group I developed complication more frequently than those in group II. Although no statistically significant difference between the two groups was seen as regard the ejection fraction sought by echocardiography, it did show a higher incidence of mitral regurg in group I [14 (70%)] versus 6 (30%) in group II with P value of 0.01. In group I left anterior descending artery lesions was significantly more frequent than in group II, P value <0.001, also multivessel disease was significantly more frequent in group I. Conclusions: The significance of reciprocal ST depression on the electrocardiogram during the course of inferior MI remains uncertain, opinion is divided as to whether it is a bengin electrical phenomenon or a sign of a greater myocardial necrosis and more frequent left coronary artery disease, from our study we support the latter opnion. This simple ECG finding may be used to differentiate high risk patients for a more aggressive approach.
PP-372 COEXISTENCE OF CROUZON SYNDROME WITH DILATE CARDIOMYOPATHY: CASE REPORT O. Uz, F. Kilicaslan, Z. Isilak, M. Yalcin, O. Yiginer, M. Dogan. Department of Cardiology, GATA Haydarpasa Training and Research Hospital, Istanbul, Turkey Objective: Crouzon syndrome is an autosomal dominant transmitted congenital disease. Mostly fibroblast growth factor receptor 2 gene mutation causes skeletal defects, especially effects cranium. There is one case reported that coexistance of crouzon syndrome and ventricular septal defect. This case report presents the coexistence of crouzon syndrome and dilate cardiomyopathy. Methods: 24 years old male patient is admitted to our department with dyspnea on exertion which has started from childhood. There was no sign related with having an infection recently according to anamnesis. Maxillary hypoplasia, exophthalmia, hypertelorism, mandibular prognatism and pectus excavatus are detected on physical examination. Arterial blood pressure was 120/80 mmhg, heart rate was 73 beat per minute and there was 1/6 systolic regurgitant sufl on mesocardiac area. Laboratory researchs like routine biochemistry and tests for dilate cardiomyopathy did not show any speciality. Electrocardiography was normal sinus rhythm. Transthoracic echocardiography showed left ventriculary dilatation (left ventricular end diastolic diameter: 64 mm, end systolic diameter: 52 mm), mild tricuspit regurgitation, estimated pulmonary artery pressure: 41 mmHg, left ventricule ejection fraction: %36, and global hypokinesia. Results: Crouzon syndrome is one of the craniosinostosis syndrome, which is characterized by cranial sinostosis, maxillary hypoplazia, parrot hook nose, exophthalmus, strabismus, hypertelorism, small upper lip, relative mandibular prognatism. There were dilate cardiomyopathy findings on physical examination. For the etiology researches of dilate cardiomyopathy, nothing has found as ischemic origin or other metabolic, infectious, inflammatory, toxic etc. reason. Mostly the gene mutation which code fibroblast growth factor receptor 2 causes congenital anomalies. After examination of the patient who has accompanying of Acanthosis nigricans and Crouzon syndrome, fibroblast growth factor receptor 3 gene mutation is reported. These fibroblast growth factor receptors (FGFRs) mutations often hold congenital disorders of bone structure. In addition fibroblast growth factor receptor may effect the development process of many areas from beginning to ending. We can give examples like mesoderm specification, vascular proliferation, bone and cartilage differentiation. Because of these fibroblast growth factor receptors can impair many areas, FGF receptor gene mutation may be seen with wider phenotype expression and complex congenital anomalies. Conclusions: Patient with Crouzon syndrome and dilate cardiomyopathy diagnosis have never been presented together before and the possibility of this syndrome may be seen with some kind of cardiac anomalies, that’s why that case is suitable to be presented. PP-373 EXCISION OF RECURRENT RA MYXOMA AND RECONSTRUCTION OF RA & SVC WITH BOVINE PERICARDIUM S. Ahmed, M. Wadwani, P. Dutta, A. Chauhan, V. Bhargava, M. Aquil, S. Motwani, S. Attawar. Narayana Hrudayalaya Hospitals, Jaipur, India Objective: Cardiac myxomas are rare benign tumours, which account for nearly 50% of all adult primary cardiac tumours. Approximately 75% to 80% of myxomas are located in the left atrium, 10% to 20% are in the right atrium, and 5% to 10% are in both atria or either ventricle.2 Typically solitary, pedunculated, and arising in the vicinity of the fossa ovalis, they may on occasion be multicentric, sessile, or attached to other
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
areas of endocardium. Clinically they present with symptoms of haemodynamic obstruction, embolization, or constitutional changes. Diagnosis at present is established most appropriately with two dimensional echocardiography. Recurrence of Myxoma is common if it is not removed properly from its attachment wall through wide excision. Here we present a case of a middle aged lady who presented with recurrence of RA myxoma. After necessary evaluation we excised the tumour from RA. But it required wide excision of RA & part of SVC. We reconstructed the RA & SVC with bovine pericardium. She was discharged from hospital uneventfully. Reconstruction of RA & SVC can easily done with bovine pericardium if large area of those structures need to be sacrificed due to invasion of tumours with subsequent good results. Peripheral Arteries: New Therapeutic Targets in Cardiovascular Medicine PP-375 TRANSCATHETER CLOSURE OF CONGENITAL CORONARY ARTERIAL MULTIPLE FISTULAS IN ADULTS WITH GRAFT STENT H. Kılıc¸ 1 , R. Akdemir2 . 1 Dıskapı ¸ Yıldırım Beyazıt E˘gitim ve Arastırma ¸ Hastanesi, Ankara, Turkey; 2 Sakarya University, Department of Cardiology, Sakarya, Turkey Objective: Coronary artery fistulas are unusual congenital coronary artery abnormalities in which blood is shunted into a cardiac chamber, great vessel or other structure, bypassing the myocardial capillary network. Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. Methods: Percutaneous closure was performed, using the right femoral artery for access with a JL 4 8F guiding catheter into the left coronary artery. 3.0*20 mm (Abbott Vascular) coronary graft stent was deployed in the coronary artery to occlude the multiple fistulas. Results: The procedure was uncomplicated. At follow up, patient underwent short term coronary angiography with good results. Patient’s chest pain or dyspnea have resolved after the procedure. Long term follow patient had a in stent restenosis. Conclusions: Surgical correction of multiple fistulas are difficult. However percutaneous graft stenting is as a safe and effective alternative therapy. Long term high incidence of graft stent restenosis is problem.
Figure: Coronary artery multiple fistulas.
S221
PP-377 PRIMARY CARDIAC ANGIOSARCOMA WITH C-KIT (CD 117) EXPRESSION A.I. Rezk. King Fahad Military Hospital, Jeddah, Saudi Arabia Objective: Primary angiosarcoma of the heart is extremely rare. The clinical presentation is non-specific, and prognosis is usually poor. The diagnosis is confirmed by combined histopathologic and immunohistochemical studies. Very few studies have addressed the expression of c-kit (CD117) in primary cardiac angiosarcoma. Methods: A 33-year-old man presented initially to a peripheral hospital with severe shortness of breath and chest pain radiating to the back. After one month of hospitalization, the patient was referred to our center with low cardiac output and clinical features of cardiac tamponade. Echocardiography revealed massive pericardial effusion with a right atrial mass. Transesophageal echocardiography and computed tomography confirmed presence of a mass in the right atrium. Emergency surgery was performed, and complete resection was done. Results: Histologically, the mass revealed a high grade malignant tumor forming anastomosing channels with tumor necrosis and frequent mitoses. The tumor cells expressed CD34, factor VIII and c-kit (CD117). Conclusions: These findings support the diagnosis of high-grade angiosarcoma. The expression of c-kit (CD117) is extremely rarely reported in primary cardiac angiosarcoma. PP-400 A CASE OF CEREBRAL ANEURYSM IN A PATIENT WITH LOSS OF CONSCIOUSNESS AND ST ELEVATION 1 E. Buy ¨ ukkaya ¨ , M.F. Karakas¸ 1 , A.B. Akcay ¸ 1 , M. Gung ¨ or ¨ 1 , M. Kurt1 , Z. Kaya2 , Y. I˙ slamo˘glu3 , P. Bilen1 , N. Sen ¸ 1 . 1 Department of Cardiology, Mustafa Kemal University, Hatay, Turkey; 2 Department of Cardiology, Harran University, Sanlıurfa, ¸ Turkey; 3 Department of Cardiology, Dicle University, Diyarbakır, Turkey Objective: The incidence of inracranial aneurysms is %5 in community, most of which are asymptomatic. Intracranial aneurysms may lead to clinical findings by three different ways. The mass effect and brain stem compression is one of these ways Some aneurysms were reported to cause motor loss, hemodynamic disturbances and epileptic seizures via brain stem compression. It was also reported that the rupture of aneurysm may lead to vasospasm. Mediators causing vasospasm act on coronary arteries and may cause acute coronary syndromes because of the vasospasm in the coronary arteries. Here we present the coexistence of cerebral aneurysm and acute myocardial infarction in a case admitted to emergency department with loss of consciousness and epileptic seizure. Methods: The patient is a 47 year old male admitted to the emergency room with a chief complaint of sudden loss of consciousness and generalized spasm. In the ECG, ST segment elevation in II-III and aVF and ST segment depression in V1–3 were present (Figure 1). The patient seemed confused and physical examination revealed a blood pressure of 100/80 mmHg, spontaneous breathing and otherwise normal findings. Laboratory findings on admission were WBC:15300, Hb:15.3 g/dL, Htc:44.3, Plt:149000, Glu:219, AST:106 ALT:73 UN:14 Cre:1.1 Na:133 K:3.7 Troponin:0.10. The mental confusion of the patient was thought to be caused by cerebral hypoperfusion related to cardiac arryhmia. The patient was taken to the catheter laboratory with the diagnosis of acute myocardial infarction and coronary angiogram revealed normal coronary arteries (Figure 2). The control laboratory measures were as CK:1441, CKMB:191 and Trop:36.6. There was hypokinesia in the inferior wall with transthoracic echocardiography. The mental status of the patients had got worse and the patient was entubated and mechanically intubated, because of the shallowing of breathing. The general status of the patient got worse and a cranial CT scan was performed and
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
Methods: She complained from fatigue and dyspnea (NYHA III-IV FC), edema of the legs, ECG – LBBB, sinusu rhythm. Echocardiography confrmed the restrictive cardiomyopathy with dyastolic dysfunction, relatively preserved ejection fraction of both ventricles. The simultaneous left and right heart catheterization, with left and right ventriculography during 2009 in the National Heart Hospital diagnosed showed no changes in the coronary anatomy, with significant right and left ventricular hypertrophy. Results: During previous hospitalizations connective tissue disease was rejected, with negative laboratory results for antiphospholipid antibodies, two times negative subcutaneous biopsy for amyloidosis, which was suspected due to the typical clinical findings. After the hospitalization in our clinic besides the NYHA III-IV FC heart insufficeincy, later compensated hypopotassiemia was confrimed. After the ezplaining the risks of the procedure, in order to achieve exact diagnose and confirm or reject the suspected amyloidosis, the patient was proposed an ednomyocardial biopsy, which was made in our clinic. Conclusions: On 04.02.2011 after right heart catheterization, three samples from the right ventricle myocardium were taken and were sent to hystologic analysis, while the procedure itself passed without serious complications. The results of the hystologic analysis showed isolated, type AA cardiac amyloidosis, which is a very rare finding. The patient was feeling relatively well with medical therapy and waits for the suitable donor to receive heart transplantation. PP-371 RECIPROCAL ST SEGMENT CHANGES IN ACUTE INFERIOR MYOCARDIAL INFARCTION: CLINICAL, HEMODYNAMIC AND ANGIOGRAPHIC IMPLICATIONS M.A. Shehata1 , H.A. Effat3 , H.A. El Atroush2 . Critical Care Medicine, Cairo University, Cairo, Egypt Objective: To investigate the clinical significance of reciprocal ST segment depression on the presenting electrocardiogram in patients with acute inferior myocardial infarction. Design and Setting: A prospective, randomized, controlled single center study done in the critical care department, Cairo university Hospital. Subjects: Forty consecutive patients with acute inferior myocardial infarction were enrolled in this study divided into two groups, 20 patients with reciprocal ST depression (Group I) and 20 patients without such depression (Group II). Interventions: All patients were investigated with serial ECG, cardiac biomarkers, echocardiography and coronary angiography. Results: There was no significant differences in the proportion of coronary disease risk factors in patients in group I, versus those in group II. Patients in group I had significant higher degree ST elevation (in inf. Leads) than patients in group II, higher levels of peak total CPK and CKMB was also seen. In addition patients in group I developed complication more frequently than those in group II. Although no statistically significant difference between the two groups was seen as regard the ejection fraction sought by echocardiography, it did show a higher incidence of mitral regurg in group I [14 (70%)] versus 6 (30%) in group II with P value of 0.01. In group I left anterior descending artery lesions was significantly more frequent than in group II, P value <0.001, also multivessel disease was significantly more frequent in group I. Conclusions: The significance of reciprocal ST depression on the electrocardiogram during the course of inferior MI remains uncertain, opinion is divided as to whether it is a bengin electrical phenomenon or a sign of a greater myocardial necrosis and more frequent left coronary artery disease, from our study we support the latter opnion. This simple ECG finding may be used to differentiate high risk patients for a more aggressive approach.
PP-372 COEXISTENCE OF CROUZON SYNDROME WITH DILATE CARDIOMYOPATHY: CASE REPORT O. Uz, F. Kilicaslan, Z. Isilak, M. Yalcin, O. Yiginer, M. Dogan. Department of Cardiology, GATA Haydarpasa Training and Research Hospital, Istanbul, Turkey Objective: Crouzon syndrome is an autosomal dominant transmitted congenital disease. Mostly fibroblast growth factor receptor 2 gene mutation causes skeletal defects, especially effects cranium. There is one case reported that coexistance of crouzon syndrome and ventricular septal defect. This case report presents the coexistence of crouzon syndrome and dilate cardiomyopathy. Methods: 24 years old male patient is admitted to our department with dyspnea on exertion which has started from childhood. There was no sign related with having an infection recently according to anamnesis. Maxillary hypoplasia, exophthalmia, hypertelorism, mandibular prognatism and pectus excavatus are detected on physical examination. Arterial blood pressure was 120/80 mmhg, heart rate was 73 beat per minute and there was 1/6 systolic regurgitant sufl on mesocardiac area. Laboratory researchs like routine biochemistry and tests for dilate cardiomyopathy did not show any speciality. Electrocardiography was normal sinus rhythm. Transthoracic echocardiography showed left ventriculary dilatation (left ventricular end diastolic diameter: 64 mm, end systolic diameter: 52 mm), mild tricuspit regurgitation, estimated pulmonary artery pressure: 41 mmHg, left ventricule ejection fraction: %36, and global hypokinesia. Results: Crouzon syndrome is one of the craniosinostosis syndrome, which is characterized by cranial sinostosis, maxillary hypoplazia, parrot hook nose, exophthalmus, strabismus, hypertelorism, small upper lip, relative mandibular prognatism. There were dilate cardiomyopathy findings on physical examination. For the etiology researches of dilate cardiomyopathy, nothing has found as ischemic origin or other metabolic, infectious, inflammatory, toxic etc. reason. Mostly the gene mutation which code fibroblast growth factor receptor 2 causes congenital anomalies. After examination of the patient who has accompanying of Acanthosis nigricans and Crouzon syndrome, fibroblast growth factor receptor 3 gene mutation is reported. These fibroblast growth factor receptors (FGFRs) mutations often hold congenital disorders of bone structure. In addition fibroblast growth factor receptor may effect the development process of many areas from beginning to ending. We can give examples like mesoderm specification, vascular proliferation, bone and cartilage differentiation. Because of these fibroblast growth factor receptors can impair many areas, FGF receptor gene mutation may be seen with wider phenotype expression and complex congenital anomalies. Conclusions: Patient with Crouzon syndrome and dilate cardiomyopathy diagnosis have never been presented together before and the possibility of this syndrome may be seen with some kind of cardiac anomalies, that’s why that case is suitable to be presented. PP-373 EXCISION OF RECURRENT RA MYXOMA AND RECONSTRUCTION OF RA & SVC WITH BOVINE PERICARDIUM S. Ahmed, M. Wadwani, P. Dutta, A. Chauhan, V. Bhargava, M. Aquil, S. Motwani, S. Attawar. Narayana Hrudayalaya Hospitals, Jaipur, India Objective: Cardiac myxomas are rare benign tumours, which account for nearly 50% of all adult primary cardiac tumours. Approximately 75% to 80% of myxomas are located in the left atrium, 10% to 20% are in the right atrium, and 5% to 10% are in both atria or either ventricle.2 Typically solitary, pedunculated, and arising in the vicinity of the fossa ovalis, they may on occasion be multicentric, sessile, or attached to other
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
areas of endocardium. Clinically they present with symptoms of haemodynamic obstruction, embolization, or constitutional changes. Diagnosis at present is established most appropriately with two dimensional echocardiography. Recurrence of Myxoma is common if it is not removed properly from its attachment wall through wide excision. Here we present a case of a middle aged lady who presented with recurrence of RA myxoma. After necessary evaluation we excised the tumour from RA. But it required wide excision of RA & part of SVC. We reconstructed the RA & SVC with bovine pericardium. She was discharged from hospital uneventfully. Reconstruction of RA & SVC can easily done with bovine pericardium if large area of those structures need to be sacrificed due to invasion of tumours with subsequent good results. Peripheral Arteries: New Therapeutic Targets in Cardiovascular Medicine PP-375 TRANSCATHETER CLOSURE OF CONGENITAL CORONARY ARTERIAL MULTIPLE FISTULAS IN ADULTS WITH GRAFT STENT H. Kılıc¸ 1 , R. Akdemir2 . 1 Dıskapı ¸ Yıldırım Beyazıt E˘gitim ve Arastırma ¸ Hastanesi, Ankara, Turkey; 2 Sakarya University, Department of Cardiology, Sakarya, Turkey Objective: Coronary artery fistulas are unusual congenital coronary artery abnormalities in which blood is shunted into a cardiac chamber, great vessel or other structure, bypassing the myocardial capillary network. Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. Methods: Percutaneous closure was performed, using the right femoral artery for access with a JL 4 8F guiding catheter into the left coronary artery. 3.0*20 mm (Abbott Vascular) coronary graft stent was deployed in the coronary artery to occlude the multiple fistulas. Results: The procedure was uncomplicated. At follow up, patient underwent short term coronary angiography with good results. Patient’s chest pain or dyspnea have resolved after the procedure. Long term follow patient had a in stent restenosis. Conclusions: Surgical correction of multiple fistulas are difficult. However percutaneous graft stenting is as a safe and effective alternative therapy. Long term high incidence of graft stent restenosis is problem.
Figure: Coronary artery multiple fistulas.
S221
PP-377 PRIMARY CARDIAC ANGIOSARCOMA WITH C-KIT (CD 117) EXPRESSION A.I. Rezk. King Fahad Military Hospital, Jeddah, Saudi Arabia Objective: Primary angiosarcoma of the heart is extremely rare. The clinical presentation is non-specific, and prognosis is usually poor. The diagnosis is confirmed by combined histopathologic and immunohistochemical studies. Very few studies have addressed the expression of c-kit (CD117) in primary cardiac angiosarcoma. Methods: A 33-year-old man presented initially to a peripheral hospital with severe shortness of breath and chest pain radiating to the back. After one month of hospitalization, the patient was referred to our center with low cardiac output and clinical features of cardiac tamponade. Echocardiography revealed massive pericardial effusion with a right atrial mass. Transesophageal echocardiography and computed tomography confirmed presence of a mass in the right atrium. Emergency surgery was performed, and complete resection was done. Results: Histologically, the mass revealed a high grade malignant tumor forming anastomosing channels with tumor necrosis and frequent mitoses. The tumor cells expressed CD34, factor VIII and c-kit (CD117). Conclusions: These findings support the diagnosis of high-grade angiosarcoma. The expression of c-kit (CD117) is extremely rarely reported in primary cardiac angiosarcoma. PP-400 A CASE OF CEREBRAL ANEURYSM IN A PATIENT WITH LOSS OF CONSCIOUSNESS AND ST ELEVATION 1 E. Buy ¨ ukkaya ¨ , M.F. Karakas¸ 1 , A.B. Akcay ¸ 1 , M. Gung ¨ or ¨ 1 , M. Kurt1 , Z. Kaya2 , Y. I˙ slamo˘glu3 , P. Bilen1 , N. Sen ¸ 1 . 1 Department of Cardiology, Mustafa Kemal University, Hatay, Turkey; 2 Department of Cardiology, Harran University, Sanlıurfa, ¸ Turkey; 3 Department of Cardiology, Dicle University, Diyarbakır, Turkey Objective: The incidence of inracranial aneurysms is %5 in community, most of which are asymptomatic. Intracranial aneurysms may lead to clinical findings by three different ways. The mass effect and brain stem compression is one of these ways Some aneurysms were reported to cause motor loss, hemodynamic disturbances and epileptic seizures via brain stem compression. It was also reported that the rupture of aneurysm may lead to vasospasm. Mediators causing vasospasm act on coronary arteries and may cause acute coronary syndromes because of the vasospasm in the coronary arteries. Here we present the coexistence of cerebral aneurysm and acute myocardial infarction in a case admitted to emergency department with loss of consciousness and epileptic seizure. Methods: The patient is a 47 year old male admitted to the emergency room with a chief complaint of sudden loss of consciousness and generalized spasm. In the ECG, ST segment elevation in II-III and aVF and ST segment depression in V1–3 were present (Figure 1). The patient seemed confused and physical examination revealed a blood pressure of 100/80 mmHg, spontaneous breathing and otherwise normal findings. Laboratory findings on admission were WBC:15300, Hb:15.3 g/dL, Htc:44.3, Plt:149000, Glu:219, AST:106 ALT:73 UN:14 Cre:1.1 Na:133 K:3.7 Troponin:0.10. The mental confusion of the patient was thought to be caused by cerebral hypoperfusion related to cardiac arryhmia. The patient was taken to the catheter laboratory with the diagnosis of acute myocardial infarction and coronary angiogram revealed normal coronary arteries (Figure 2). The control laboratory measures were as CK:1441, CKMB:191 and Trop:36.6. There was hypokinesia in the inferior wall with transthoracic echocardiography. The mental status of the patients had got worse and the patient was entubated and mechanically intubated, because of the shallowing of breathing. The general status of the patient got worse and a cranial CT scan was performed and