Browsing by Author "Erdogan, Emrah"

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Acute Mitral Valve Endocarditis Complicated by Complete Atrioventricular Block, Junctional Escape Rhythm, and Skin Manifestations
(Turkish Soc Cardiology, 2019) Cap, Murat; Erdogan, Emrah
The Association of Left Ventricular End-Diastolic Pressure With Global Longitudinal Strain and Scintigraphic Infarct Size in St-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention
(Springer, 2021) Cap, Murat; Erdogan, Emrah; Karagoz, Ali; Den Hartigh, Ozden Savas; Acar, Rezzan Deniz; Gecmen, Cetin; Ozdemir, Nihal
Left ventricular end-diastolic pressure (LVEDP) is an independent predictor for prognosis in ST-elevation myocardial infarction (STEMI) patients. We aimed to investigate the relationship of admission LVEDP measured after a successful primary percutaneous coronary intervention (pPCI) with scintigraphic infarct size (IS) and global longitudinal strain (GLS), a strong predictor of IS, in STEMI patients. A total of 62 consecutive patients with STEMI were enrolled in the study. LVEDP measurements were performed after pPCI in patients who had TIMI-3 flow. Echocardiography was performed 24 h after pPCI and repeated 3 months later. GLS was calculated as an average peak strain from the 3 apical projections. IS was evaluated at the third month by technetium 99m sestamibi. The mean age was 56 +/- 8 years in the study population. The mean LVEDP was found 19.4 +/- 4.4 mmHg. Median IS was 4% (0-11.7 IQR).The mean GLS at the 24th hour and the third month were found to be - 15.4 +/- 2.8 and - 16.7 +/- 2.5 respectively. There was a moderate negative correlation between LVEDP and GLS (24th-hour p < 0.001 r = - 0.485 and third-month p < 0.001 r = - 0.489). LVEDP had a moderate positive correlation with scintigraphic IS (p < 0.001 r = 0.545). In the multivariable model, we found that LVEDP was significantly associated with scintigraphic IS (beta coefficient = 0.570, p = 0.008) but was not associated with the 24th hour (beta coefficient = 0.092, p = 0.171) and third month GLS (beta coefficient = 0.037, p = 0.531). This study demonstrated that there was a statistically significant relationship between LVEDP and scintigraphic IS, and IS was increased with high LVEDP values. However, there was not a relationship between LVEDP and GLS.
An Atypical Cause of Chest Pain
(Cambridge Univ Press, 2022) Erdogan, Emrah; Kilic, Yakup
Congenital coronary artery anomalies are of major significance in clinical cardiology and cardiac surgery due to their association with myocardial ischaemia and sudden death. Having a multidisciplinary approach in managing complex congenital conditions and including patients in the management decisions is essential for good doctor-patient relationship. Here within, we describe a complex coronary artery fistula leading to myocardial steal.
An Automated Software for Real-Time Quantification of Wall Shear Stress Distribution in Quantitative Coronary Angiography Data
(Elsevier Ireland Ltd, 2022) Tufaro, Vincenzo; Torii, Ryo; Erdogan, Emrah; Kitslaar, Pieter; Koo, Bon-Kwon; Rakhit, Roby; Bourantas, Christos, V
Background: Wall shear stress (WSS) estimated in 3D-quantitative coronary angiography (QCA) models appears to provide useful prognostic information and identifies high-risk patients and lesions. However, conventional computational fluid dynamics (CFD) analysis is cumbersome limiting its application in the clinical arena. This report introduces a user-friendly software that allows real-time WSS computation and examines its reproducibility and accuracy in assessing WSS distribution against conventional CFD analysis. Methods: From a registry of 414 patients with borderline negative fractional flow reserve (0.81-0.85), 100 lesions were randomly selected. 3D-QCA and CFD analysis were performed using the conventional approach and the novel CAAS Workstation WSS software, and QCA as well as WSS estimations of the two approaches were compared. The reproducibility of the two methodologies was evaluated in a subgroup of 50 lesions.Results: A good agreement was noted between the conventional approach and the novel software for 3D-QCA metrics (ICC range: 0.73-0-93) and maximum WSS at the lesion site (ICC: 0.88). Both methodologies had a high reproducibility in assessing lesion severity (ICC range: 0.83-0.97 for the conventional approach; 0.84-0.96 for the CAAS Workstation WSS software) and WSS distribution (ICC: 0.85-0.89 and 0.83-0.87, respectively). Simulation time was significantly shorter using the CAAS Workstation WSS software compared to the conventional approach (4.13 +/- 0.59 min vs 23.14 +/- 2.56 min, p < 0.001).Conclusion: CAAS Workstation WSS software is fast, reproducible, and accurate in assessing WSS distribution. Therefore, this software is expected to enable the broad use of WSS metrics in the clinical arena to identify highrisk lesions and vulnerable patients.
Dcb Combined With Provisional Des Implantation in the Treatment of De Novo Medina 0,1,0 or 0,0,1 Left Main Coronary Bifurcation Lesions: a Proof-Of Study
(Aves, 2022) Erdogan, Emrah; Li, Zheng; Zhu, Yong-Xiang; Tufaro, Vincenzo; Feng, Si-Li; Li, Qian; Zhang, Yao-Jun
Objective: To investigate the safety and efficacy of a percutaneous revascularization strategy that is based on the use of drug-coated balloon for the treatment of patients with acute coronary syndrome and de novo Medina type 0,1,0 or 0,0,1Ieft main stem bifurcation lesions. Methods: In this multicenter, prospective, proof-of-concept study, patients fulfilling the above criteria were enrolled and received treatment with drug-coated balloon combined with provisional drug-eluting stent implantation in the proximal major branches of the left main stem. Patients who declined this revascularization approach were treated with drug-eluting stent implantation 1-2 mm distally to the left anterior descending or left circumflex artery ostium followed by drug-coated balloon therapy for the ostial disease. The primary endpoint of the study was the calculation of percent diameter stenosis on quantitative coronary angiography post-procedure as well as event rate at 8 months follow-up. Results: A total of 30 patients were enrolled in the study; their mean age was 60.3 +/- 7.8 years, while 22 (73.3%) were male. Twenty-two patients were treated only with drug-coated balloon and provisional drug-eluting stent implantation and 8 had drug-eluting stent implantation followed by drug-coated balloon therapy of the ostium of the left main stem major branch. All the procedures were successful with no immediate complications. The percent diameter stenosis of lesion decreased significantly post-procedure from 87.5% (80.0-90.0) to 20% (17.5-30.0), P < .001. During the follow-up period, no major adverse cardiac events were reported. Conclusions: This proof-of-concept study indicates that ostial drug-coated balloon therapy of the left main stem major branches is safe and effective. Larger clinical data and longer follow-up are needed before advocating its regular use in clinical practice.
Early Qtc Interval Prolongation After Primary Percutaneous Coronary Intervention May Have a Positive Impact
(2021) Bilge, Önder; Karagöz, Ali; Erdogan, Emrah; Işık, Ferhat; Geçmen, Çetin; Kaymaz, Cihangir; Özdemir, Nihal
Objectives: Corrected QT (QTc) interval is prolonged in acute myocardial infarction and begins to shorten after successful reperfusion. Data on the early change of QTc after reperfusion and the prognostic significance of this change are limited. We aimed to evaluate the change of QTc interval in the first hour following successful primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) patients and its relationship with reperfusion parameters such as myocardial blush grade (MBG) and ST-segment resolution (STR%). Materials and Methods: Patients who presented with the first STEMI episode and underwent successful pPCI were included in the study. After pPCI, MBG and STR% were calculated. QTc measurements were made from the electrocardiography (ECG) recorded at admission (Pre-pPCI QTc), 1 hour after pPCI (Post-pPCI QTc), and the 24th hour. Results: One hundred and five patients who had successful pPCI with adequate ECG data were enrolled in the study. The mean Pre-pPCI QTc was 409±34 ms, and the mean post-pPCI QTc was 427±32 ms. A statistically significant prolongation was observed in the QTc interval after pPCI (QTc-Change) [21 ms (-3, 37 interquartile range (IQR)), p<0.001]. The median STR was 71% (60-83 IQR), and the median MBG was 2 (1-3 IQR). In the multivariable linear regression analysis, a significant relationship was observed between QTc-Change with MBG and STR%Conclusion: It was found that the QTc interval continued to prolong somewhat in the early period after successful pPCI in STEMI patients, and this QTc-Change was significantly associated with reperfusion parameters such as MBG and STR%. STR% and MBG were higher in those with higher QTc-Change.
Early Systolic Lengthening Is Associated With Syntax Score in Patients With Non-St Acute Coronary Syndrome
(Kare Publ, 2024) Unkun, Tuba; Gecmen, Cetin; Cap, Murat; Izci, Servet; Erdogan, Emrah; Onal, Cagatay; Ozdemir, Nihal
Background: Early systolic lengthening is a echocardiographic strain parameter previously used to determine the lesion severity in patients with stable coronary artery disease. In the present study, we aimed to evaluate the relationship between early systolic lengthening and anatomic SYNTAX score in troponin (-) and (+) groups among patients with non-ST-elevation acute coronary syndrome (ACS). Methods: A total of 95 patients diagnosed with non-ST-elevation ACS were included in the prospective, non-randomized, single-center study. The patients were categorized into 2 groups as troponin (+) and troponin (-). The patients were evaluated in terms of echocardiographic, clinical, and angiographic parameters. Results: The baseline characteristics, including age (58 +/- 13 vs. 60 +/- 10 respectively, P=.340), a history of hypertension (67.1% vs. 64%, respectively, P=.479), diabetes (28.6% vs. 32%, respectively, P=.467), global longitudinal strain (-14.37 +/- 5.11 vs. -16.42 +/- 3.93, respectively, P=.095), left ventricular ejection fraction (58.71 +/- 8.73 vs. 57.20 +/- 8.70, respectively, P=.263), and E/e' (8.44 +/- 2.13 vs. 8.33 +/- 1.99, respectively, P=.785), were similar between troponin (+) and troponin (-) groups. Left ventricle end-systolic diameter (3.2 +/- 0.78; 3.50 +/- 0.74 vs. 3.2 +/- 0.78, respectively, P=.031), left ventricle end-systolic volume (55.57 +/- 32.17 vs. 38.28 +/- 13.63, respectively, P=.013), left ventricle end-diastolic volume (115.31 +/- 49.54 vs. 91.23 +/- 20.57, respectively, P=.042), the rate of early systolic lengthening (65.7% vs. 28%, respectively, P=.001), the duration of early systolic lengthening (24.02 +/- 31 ms vs. 15.56 +/- 30.19 ms, respectively, P=.009), and the SYNTAX score (16 +/- 11 vs. 10 +/- 10, respectively, P=.023) were higher in the troponin (+) group. Furthermore, a significant correlation was found between early systolic lengthening and SYNTAX score (r = 0.43, P < .001). Conclusion: The rate and duration of early systolic lengthening were higher in patients in the troponin (+) group. Early systolic lengthening is related to SYNTAX score in patients with non-ST-elevation ACS.
The Effect of Coronavirus Disease 2019 Pneumonia on Myocardial Ischemia Detected by Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging
(Lippincott Williams & Wilkins, 2022) Bilge, Onder; Komek, Halil; Kepenek, Ferat; Tastan, Ercan; Gundogan, Cihan; Tatli, Ismail; Erdogan, Emrah
Objective We aimed to examine the effects of COVID-19 pneumonia on cardiac ischemia detected by myocardial perfusion imaging with single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in patients presenting with chest pain and shortness of breath after recovery from COVID-19. Materials and method Patients with a history of COVID-19 confirmed by reverse transcriptase-PCR test who underwent SPECT-MPI for the evaluation of ischemia with the complaints of chest pain and shortness of breath were screened for this study. Patients who underwent thorax CT during the acute period of the COVID-19 were included. Patients with and without pneumonia were determined based on computed tomographic criteria. The patients with a summed stress score of at least 4 on SPECT-MPI were considered to have abnormal MPI in terms of ischemia. Results A total of 266 patients were included in the study. Sixty-five (24%) patients had ischemia findings on SPECT-MPI. Thorax CT showed pneumonia in 152 (57%) patients, and the patients were divided into two groups as pneumonia and nonpneumonia. Abnormal SPECT-MPI scores, which represented myocardial ischemia, were higher in the pneumonia group. Multivariate logistic regression analyses showed that the presence of hyperlipidemia and pneumonia on CT increased the risk of ischemia on SPECT-MPI (OR, 2.08; 95% CI, 1.08-3.99; P-value = 0.029; and OR, 2.90; 95% Cl, 1.52-5.54; P-value = 0.001, respectively). Conclusion COVID-19 pneumonia was identified as an independent predictor of ischemia on SPECT-MPI. Symptoms including chest pain and shortness of breath in patients who have had COVID-19 pneumonia may be attributed to coronary ischemia.
The Effect of Prior Covid-19 Infection on Coronary Microvascular Dysfunction
(Taylor & Francis Ltd, 2022) Bilge, Onder; Cap, Murat; Kepenek, Ferat; Erdogan, Emrah; Tatli, Ismail; Ozturk, Cansu; Tanboga, Ibrahim Halil
Background Thrombolysis in Myocardial Infarction Frame Count (TFC) is an index that provides a quantitative evaluation of coronary microvascular dysfunction. In this study, we aimed to examine the effect of COVID-19 infection on TFC in patients admitted with chest pain and dyspnoea after COVID-19 disease and had abnormal findings in myocardial perfusion scintigraphy. Methods For this single-center retrospective study, patients with and without a history of COVID-19 who were underwent coronary angiography for abnormal findings in myocardial perfusion scintigraphy between January 1, 2021 and June 30, 2021 were analysed. Patients were divided into two groups as patients with COVID-19 history and those without. After exclusion criteria, patients with adequate angiographic monitoring and data were included in the study. Results A total of 210 patients, 48 with a history of COVID-19, were included in the study. The mean age was +/- 55 10 years, and 122 (58%) patients were women. In patients with a history of COVID-19, TFC was significantly higher in the LAD (p < 0.001) and LCx (p < 0.001) arteries and RCA TFC (p = 0.223) was similar in both groups. In the linear mix model, male gender (beta = 2.38, 95% CI = 1.26-3.51, p < 0.001) and history of COVID-19 (beta = 1.51, 95% CI = 0.49-2.53, p = 0.004) were significantly associated with TFC. Conclusion TFC may be elevated due to coronary microvascular dysfunction in patients with a history of COVID-19.
Electrocardiographically Gated Intravascular Image Segmentation Enables More Reproducible Volumetric Analysis of Atheroma Burden
(Elsevier Science inc, 2021) Erdogan, Emrah; Huang, Xingru; Cooper, Jackie; Jain, Ajay; Ramasamy, Anantharaman; Bajaj, Retesh; Bourantas, Christos
End-Diastolic Segmentation of Intravascular Ultrasound Images Enables More Reproducible Volumetric Analysis of Atheroma Burden
(Wiley, 2022) Erdogan, Emrah; Huang, Xingru; Cooper, Jackie; Jain, Ajay; Ramasamy, Anantharaman; Bajaj, Retesh; Bourantas, Christos V.
Background Volumetric intravascular ultrasound (IVUS) analysis is currently performed at a fixed frame interval, neglecting the cyclic changes in vessel dimensions occurring during the cardiac cycle that can affect the reproducibility of the results. Analysis of end-diastolic (ED) IVUS frames has been proposed to overcome this limitation. However, at present, there is lack of data to support its superiority over conventional IVUS. Objectives The present study aims to compare the reproducibility of IVUS volumetric analysis performed at a fixed frame interval and at the ED frames, identified retrospectively using a novel deep-learning methodology. Methods IVUS data acquired from 97 vessels were included in the present study; each vessel was segmented at 1 mm interval (conventional approach) and at ED frame twice by an expert analyst. Reproducibility was tested for the following metrics; normalized lumen, vessel and total atheroma volume (TAV), and percent atheroma volume (PAV). Results The mean length of the analyzed segments was 50.0 +/- 24.1 mm. ED analysis was more reproducible than the conventional analysis for the normalized lumen (mean difference: 0.76 +/- 4.03 mm(3) vs. 1.72 +/- 11.37 mm(3); p for the variance of differences ratio < 0.001), vessel (0.30 +/- 1.79 mm(3) vs. -0.47 +/- 10.26 mm(3); p < 0.001), TAV (-0.46 +/- 4.03 mm(3) vs. -2.19 +/- 14.39 mm(3); p < 0.001) and PAV (-0.12 +/- 0.59% vs. -0.34 +/- 1.34%; p < 0.001). Results were similar when the analysis focused on the 10 mm most diseased segment. The superiority of the ED approach was due to a more reproducible detection of the segment of interest and to the fact that it was not susceptible to the longitudinal motion of the IVUS probe and the cyclic changes in vessel dimensions during the cardiac cycle. Conclusions ED IVUS segmentation enables more reproducible volumetric analysis and quantification of TAV and PAV that are established end points in longitudinal studies assessing the efficacy of novel pharmacotherapies. Therefore, it should be preferred over conventional IVUS analysis as its higher reproducibility is expected to have an impact on the sample size calculation for the primary end point.
Intravascular Imaging for Guiding In-Stent Restenosis and Stent Thrombosis Therapy
(Wiley, 2022) Erdogan, Emrah; Bajaj, Retesh; Lansky, Alexandra; Mathur, Anthony; Baumbach, Andreas; Bourantas, Christos, V
Advances in stent technology and the design of endovascular devices with thinner struts, anti-inflammatory and antithrombotic polymers, and better drug kinetics have enhanced the safety and efficacy of the second-generation drug-eluting stents and broadened their use in the therapy of high-risk patients and complex anatomies. However, despite these developments, in-stent restenosis and stent thrombosis remain the Achilles' heel of percutaneous coronary intervention, with their cumulative incidence reaching up to 10% at 5 years following percutaneous coronary intervention. The treatment of stent failure poses challenges and is associated with a worse prognosis than conventional percutaneous coronary intervention. Several studies have recently highlighted the value of intravascular imaging in identifying causes of stent failure, underscored its role in treatment planning, and registries have shown that its use may be associated with better clinical outcomes. The present review aims to summarize the evidence in the field; it discusses the value of intravascular imaging in identifying the mechanisms of in-stent restenosis and stent thrombosis in assessing the morphological characteristics of neointima tissue that appears to determine long-term outcomes in evaluating procedural results, and presents the findings of studies supporting its value in guiding therapy in stent failure.
Myocardial Strain Assessment by 2d Speckle-Tracking Echocardiography in Patients With Congenital Myopathy
(Wolters Kluwer Medknow Publications, 2021) Cap, Murat; Akyuz, Abdurrahman; Isik, Ferhat; Turken, Askeri; Erdogan, Emrah; Varsak, Suleyman; Baysal, Erkan
Background: Congenital myopathies (CMs) are a group of rare genetic muscle disorders. Cardiac involvement can be seen in these patients. We aimed to evaluate the myocardial strain parameters by 2D speckle-tracking echocardiography (STE) in patients with CM. Materials and Methods: Twenty-four patients with CM whose diagnosis was confirmed by genetic analysis or muscle biopsy were included in the study, and 48 patients were involved as a control group. Left ventricular ejection fraction (LVEF%) was calculated by biplane Simpson method, and myocardial strain analysis was performed by 2D STE. Results: The median age of the study population was 26 (19-35 interquartile range [IQR]) and 43 (60%) were women. In the analysis performed after the exclusion of two patients with multiminicore disease (MMD) who developed heart failure, although mild, LVEF% (62 [60-65 IQR] vs. 64 [63-66 IQR], P = 0.008) and right ventricular global longitudinal strain (RVGLS) were significantly lower in the CM group (-21.8 [-19.7, -24.9 IQR] vs. -23.9 [-22.4, -25.6 IQR], P = 0.0017). Left ventricular global longitudinal strain (LVGLS) was observed similarly in both groups (-19.9 [-18.7, -20.7 IQR] vs. -20.5 [-19.3, -21.9 IQR], P = 0.069). LVEF% (33 and 46), LVGLS (-7.5 and -10.7), and RVGLS (-14.9 and -16.1) values were low in two siblings with MMD. Conclusion: Although LVEF% and RVGLS were significantly lower in the CM group, LVGLS was similar. The decrease in RVGLS and LVEF% was mild, and heart failure was not observed in any patient except MMD patients who were not included in the analysis.
Prognostic Value of 3 Nutritional Screening Tools To Predict 30-Day Outcome in Patients Undergoing Carotid Artery Stenting
(Sage Publications inc, 2022) Cakmak, Ender O.; Ocal, Lutfi; Erdogan, Emrah; Cersit, Sinan; Efe, Suleyman Cagan; Karagoz, Ali; Kirma, Cevat
The effect of malnutrition on outcomes after carotid artery stenting (CAS) is not well known. This study reports the relationship between malnutrition and post-procedure 30-day major adverse events (MAEs). A total of 978 patients hospitalized for CAS were enrolled in the study. Controlling nutritional status (CONUT) score, the nutritional risk index (NRI), and the prognostic nutritional index (PNI) were calculated. MAEs (myocardial infarction, stroke/transient ischemic attack and mortality) were compared. According to the CONUT score, NRI, and PNI, 9.4%, 41%, and 11.4% patients were moderately or severely malnourished, respectively; 74.8% were at least mildly malnourished by at least 1 score. Forty-seven patients (4.8%) had a post-procedure 30-day MAE. Continuous classifications of the indexes were independently associated with higher MAE. CONUT showed the highest predictive ability, whereas NRI had the lowest (C-index: CONUT, 0.701; NRI, 0.681; PNI, 0.688). According to categorical classification of indexes, only CONUT and PNI showed predictive ability for MAE. Malnutrition assessment could identify patients with CAS at elevated risk for MAE. CONUT, NRI, and PNI continuous scores were independent prognostic factors for the post-procedure 30-day MAE. According to our study, CONUT showed the highest predictive ability.
Progressive Pulmonary Stenosis Due To Huge Mediastinal Thymoma
(Turkish Soc Cardiology, 2021) Cap, Murat; Erdogan, Emrah; Akyuz, Abdurrahman; Cap, Nese Kanbal; Erdur, Erkan
Psoas Muscle Area Index as a Predictor of Major Adverse Cardiovascular and Limb Events in Patients With Infrarenal Aortic Occlusions
(2021) Koksal, Cengiz; Erdogan, Emrah; Sismanoglu, Mesut; Findikcioglu, Ugur; Cakmak, Ender Ozgun
Objectives: In this study, we aimed to investigate whether the total psoas muscle area index (TPAI) was a predictive factor of major adverse cardiovascular and limb events (MACLEs) in patients with infrarenal aortic occlusion (IAO). Patients and methods: Between January 2011 and December 2019, a total of 72 patients with IAO (56 males, 16 females; mean age: 58.8±7.0 years; range, 46 to 75 years) were retrospectively reviewed. The TPAI was measured by dividing total psoas muscle area to squared patient height. The primary outcome measure was MACLEs. To estimate the effect of TPAI and clinical factors on prognosis, hazard ratios (HRs) with 95% confidence intervals (CIs) were used. Results: The median follow-up was 32 months (interquartile range 15.9-44). The patients were divided into two groups as MACLE-positive (n=30, 41.6%) and MACLE-negative (n=42, 58.4%). The mean TPAI for MACLE-negative and MACLE-positive patients was 615±171 mm2/m2 and 521±129 mm2/m2, respectively (p=0.036). The presence of increased TPAI values was associated with the decreased MACLE rate (HR: 0.19; 95% CI: 0.09-0.42; p=0.008). Conclusion: Our study results indicate that the TPAI measured by computed tomography scans is an independent prognostic factor for MACLEs in patients with chronic IAO.
Reply To Letter To the Editor: "management of Coronary Ostial Stenosis With Drug Coated Balloons: Technical and Clinical Aspects
(Aves, 2022) Erdogan, Emrah; Li, Zheng; Zhu, Yong-Xiang; Tufaro, Vincenzo; Feng, Si-Li; Li, Qian; Zhang, Yao-Jun
An Unusual Case of Concurrent Kounis Syndrome and Prolonged Qt in a Young Patient
(Cambridge Univ Press, 2022) Erdogan, Emrah; Cap, Murat; Kus, Gorkem; Gokhan, Cem; Kilic, Yakup
Allergic reactions related to drug use is a common entity presenting often from minor urticaria to life-threatening anaphylactoid reactions. A common but easily overlooked diagnosis, Kounis syndrome, is an established hypersensitivity coronary disorder induced by drugs, foods, environmental factors, and coronary stents that can present in the same way as non-allergy-induced acute coronary syndrome. Here within, we present a unique case of dual presentation of Kounis syndrome and prolonged QTc in a young patient after a single dose of Domperidone and Lansoprazole.