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Background: Some patients undergoing catheter ablation for atrial fibrillation may develop typical atrial flutter on follow-up, and a second procedure for typical atrial flutter is often required in such patients. In this study, we aimed to define the variables associated with the development of typical atrial flutter after ablation., Methods: One hundred fifty-nine patients who underwent catheter ablation for the first time due to atrial fibrillation and who did not have a previously documented atrial flutter were included in the study. Before ablation, baseline clinical features and echocardiographic parameters were recorded. At the 1st, 3rd, 6th, and 12th months after the procedure, and then annually, the patients were followed up for typical atrial flutter development., Results: At a mean follow-up of 34.0 (14.0-50.0) months, typical atrial flutter developed in 21 (13.2%) patients. During the follow-up, right atrial diameter was greater in those who developed typical atrial flutter than those who did not [39.0 (38.0-43.0) vs. 36.0 (34.0-39.0) mm, P <.001]. A multiple Cox regression analysis showed that the right atrial diameter was the only independent predictor of typical atrial flutter development (hazard ratio = 1.12, 95% CI: 1.02-1.23, P =.021). A receiver operating characteristic analysis showed that the best cutoff for the right atrial diameter was 38.5 mm to predict typical atrial flutter development (area under the curve = 0.77, 95% CI: 0.67-0.86, sensitivity = 62%, specificity = 75%, P <.001)., Conclusion: In patients undergoing catheter ablation for atrial fibrillation, a pre-procedural right atrial diameter measurement may predict typical atrial flutter development at follow-up. In particular, patients with a pre-procedural right atrial diameter ≥39 mm may be at a higher risk for developing typical atrial flutter in the future.

Objective: Direct current electrical cardioversion (DCCV) is an effective rhythm-control option for patients with atrial fibrillation (AF). Despite initial success, a high recurrence rate remains a significant challenge. There is limited data on the genetic predictors of AF recurrence following successful DCCV. In this study, we aimed to evaluate whether 11 single nucleotide polymorphisms (SNPs) previously associated with AF are also linked to recurrence after DCCV in the Turkish population., Methods: Seventy-five patients with persistent AF, who achieved stable sinus rhythm following DCCV, were included in the study. The patients were prospectively monitored for the onset of AF recurrence. Clinical characteristics and SNPs were analyzed and compared between patients who experienced recurrence and those who did not., Results: The average age of the patients was 61.9 ± 11.5, and 33 (44%) were female. Over an average follow-up period of 17.0 (11.0-25.0) months, AF recurrence was observed in 38 patients (50.7%). A SNP in the PITX2 gene (rs17570669) (OR: 9.00, 95% Confidence Interval (CI): 1.28-63.02) and another in the ZFHX3 gene (rs2106261) (OR: 8.96, 95% CI: 1.03-77.66) were notably associated with AF recurrence in the additive model (P = 0.027 and 0.047, respectively). Multivariate Cox regression analysis revealed that the rs17570669 SNP was the sole independent predictor of AF recurrence (Hazard Ratio (HR): 3.59, 95% CI: 1.05-12.21, P = 0.040)., Conclusion: The SNP in the paired-like homeodomain 2 (PITX2) gene (rs17570669) emerges as an independent predictor for AF recurrence after successful electrical cardioversion.

Introduction: Complex electrophysiologic (EP) procedures are time consuming and open to complications. Accurate and rapid recognition of cardiac pathologies is essential before, during, and immediately after such procedures. In this study, we aimed to compare hand-held echocardiography (HHE) with standard echocardiography (SE) to determine whether HHE can be used as a practical and reliable diagnostic tool during such procedures., Methods: One hundred consecutive patients undergoing complex EP procedures and catheter ablation were included in the study. All patients were evaluated with SE or HHE in terms of main cardiac pathologies at the beginning and immediately after the procedure. The diagnostic accuracy and evaluation time of both methods were compared at the beginning and after the procedure. The agreement between both methods was calculated., Results: At the beginning and after the procedure, opening and evaluation times with HHE were significantly shorter than with SE ( P <0.001 for all). There was significant agreement between the two methods in the diagnosis of cardiac pathologies (Agreement was 95% for minimal mild aortic regurgitation (AR), 99% for moderate/ severe AR, 93% for minimal/ mild mitral regurgitation (MR), 95% for moderate/ severe MR, 100% for pericardial effusion, and 100% for left ventricular thrombus at the beginning of the procedure)., Conclusion: With the use of HHE during complex EP procedures, cardiac pathologies can be diagnosed with similar accuracy as SE. In addition, HHE has a significant advantage over SE in terms of time to diagnosis., Competing Interests: The authors have no relevant financial or non-financial interests to disclose., (© 2023 The Author(s).)

Background: This study aimed to assess the safety and tolerability of nebivolol in hypertensive patients with coronary artery disease and left ventricular ejection fraction ≥ 40% in a Turkish cohort., Methods: A total of 1015 hypertensive patients and coronary artery disease with left ventricular ejection fraction ≥ 40% were analyzed from 29 different centers in Turkey. Primary outcomes were the mean change in blood pressure and heart rate. Secondary outcomes were to assess the rate of reaching targeted blood pressure (<130/80 mmHg) and heart rate (<60 bpm) and the changes in the clinical symptoms (angina and dyspnea). Adverse clinical events and clinical outcomes including cardiovascular mortality, cardiovascular hospital admissions, or acute cardiac event were recorded., Results: The mean age of the study population was 60.3 ± 11.5 years (male: 54.2%). During a mean follow-up of 6 months, the mean change in blood pressure was -11.2 ± 23.5/-5.1 ± 13.5 mmHg, and the resting heart rate was -12.1 ± 3.5 bpm. Target blood pressure and heart rate were achieved in 76.5% and 37.7% of patients. Angina and functional classifications were improved by at least 1 or more categories in 31% and 23.2% of patients. No serious adverse events related to nebivolol were reported. The most common cardiovascular side effect was symptomatic hypotension (4.2%). The discontinuation rate was 1.7%. Cardiovascular hospital admission rate was 5% and hospitalization due to heart failure was 1.9% during 6 months' follow-up. Cardiovascular mortality rate was 0.1%., Conclusion: Nebivolol was well tolerated and safe for achieving blood pressure and heart rate control in hypertensive patients with coronary artery disease and heart failure with preserved or mildly reduced ejection fraction.

Objective: Genome-wide association studies have revealed that single nucleotide polymorphisms (SNPs) are associated with atrial fibrillation (AF) and can predict AF recurrence after catheter ablation in different populations. However, there exists no such data for the Turkish population. We aimed to investigate whether 11 SNPs in the PITX2, ZFHX3, EPHX2, CAV1, TBX5, TGF-1, and SCN10A were related to AF and whether these SNPs can predict long-term atrial tachyarrhythmia (ATa) recurrence after pulmonary vein isolation (PVI) for AF in Turkish patients., Methods: A total of 245 consecutive patients with non-valvular AF (44.9% men, mean age: 60.2±13.2 years, 65.3% paroxysmal AF) and 50 age- and sex-matched controls were included in this analysis. The clinical features and genetic variants were compared between the 2 groups. Of the 245 patients, 128 who underwent PVI with second-generation cryoballoon were further examined for long-term recurrence after the procedure., Results: Four SNPs in PITX2 were significantly associated with AF (rs10033464&#95;T: OR 3.29, 95%CI: 1.38-7.82, p=0.007; rs6838973&#95;T: OR 3.06, 95% CI 1.36-6.87, p=0.007; rs3853445&#95;C: OR 2.84, 95%CI: 1.27-6.36, p=0.011; rs17570669&#95;T: OR 4.03, 95% CI: 1.71-9.51, p=0.001). Among these patients who underwent PVI, one locus in CAV1 (rs3807989&#95;G: OR 4.50, 95% CI 1.04-19.31, p=0.043) and early recurrence (OR: 8.06, 95% CI: 2.12-30.55, p=0.002) predicted long-term AF recurrence after catheter ablation., Conclusion: Significant associations exists between 4 SNPs in PITX2 and AF (rs10033464, rs6838973, rs3853445, and rs17570669) in Turkish patients. In addition, 1 genetic variant in CAV1 (rs3807989) and early recurrence can predict long-term ATa recurrence after catheter ablation.

Purpose: An elevation in blood pressure (BP) during exercise is the normal physiological response, however an abnormally exaggerated rise in BP, in terms of hypertensive response to exercise (HRE), is seen as a prognostic factor for end-organ damage and mortality. HRE is more common in hypertensive (HT) patients and data are lacking on the effect of antihypertensive medication on HRE. In this study, we evaluated patients who underwent treadmill exercise testing (TET) to reveal the effect of antihypertensive medication on HRE., Materials and Methods: A cohort of 2970 individuals underwent TET and data were evaluated for HRE development. HRE has been defined as a systolic BP>210 mmHg in males and >190 mmHg in females throughout the TET. To reveal the effects of antihypertensive medication on HRE, 992 HT patients were analyzed., Results: HRE was observed in 11.4% ( n = 113) of HT patients and 5.9% ( n = 107) of non-HT individuals( p < .001). HRE was observed significantly more in males (57.6% vs. 67.3%; p = .033), and in patients with higher body mass index BMI (29.1 ± 4.5 vs. 30.3 ± 5.2;0.033). There was no significant association between medication and HRE development apart from beta-blockers. Also, gender (odds ratio:1.787; 95%CI:1.160-2.751; p = .008), BMI (odds ratio:1.070;95%CI:1.025-1.116; p = .002) and being under beta-blocker treatment (odds ratio:0.637;95%CI:0.428-0.949; p = .026) were found to be independent predictors of HRE in multivariate logistic regression analysis., Conclusion: HRE was associated with gender, BMI and beta-blocker use in hypertensive with male gender and higher BMI associated with higher HRE, while beta-blocker-based treatment, either mono- or combination therapy, associated with lower HRE.

Premature ventricular complexes (PVCs) are one of the most common arrhythmias seen in daily practice. Although PVCs are generally considered benign, they can lead to the development of cardiomyopathy and, rarely, can be associated with sudden cardiac death. Recently, the American College of Cardiology Electrophysiology Council published a state-of-the-art review on PVCs to provide diagnostic and therapeutic considerations for clinical practice. Presented are some important points about the diagnosis, approach, and treatment of PVCs.

Premature ventricular contractions (PVCs) is one of the most common situations in the current cardiology practice. Although PVCs are generally benign in people without any structural heart disease, they may be associated with left ventricular dysfunction, cardiomyopathy, and, rarely, sudden death. Recently, there has been a considerable research in the pathophysiology of PVC, several clinical presentations in different situations, new proposals of successful diagnostic methods, and treatment modalities. Finally, the American College of Cardiology Electrophysiology Council has published a special report that deals with all the aspects of PVC. We reviewed the important points from this report that can be reflected in our daily practice.

Pulmonary vein (PV) stenosis is a rare but serious complication of PV isolation. It usually develops 3-6 months after the procedure, but may rarely develop in the acute phase. We present a case of symptomatic PV stenosis within 48 hours after antral PV isolation. Following the initiation of medical treatment including a glucocorticoid, acute changes in the PV wall regressed and the patient's complaint of dyspnea at rest improved rapidly. In addition, long-term renin-angiotensin-aldosterone system (RAAS) blockers were given. The complaint did not recur during follow-up and PV stenosis was mild at 6 months.

Supraventricular tachycardias (SVTs) are common arrhythmic conditions in clinical practice. Increased knowledge and experience on SVTs and some unclear situations in clinical practice led the European Society of Cardiology (ESC) team to write a new guideline. In this review, we touch upon the important points in the new ESC 2019 SVT guidelines and present changing approaches and suggestions. By providing a general review on SVTs, we also mention the basic mechanism, epidemiology, and clinical presentation of SVTs, approaching narrow and wide QRS tachycardias, SVTs in special patient groups, and treatment of SVTs., (© 2020 S. Karger AG, Basel.)

Cerebral air embolism is a potentially life-threatening complication of left-sided ablation procedures. We present a 51-year-old woman with cerebral air embolism during atrial fibrillation cryoballoon ablation. Taking a deep breath while removing the dilatator was the most likely mechanism in our case. The patient was successfully treated with hyperbaric oxygen therapy at early stage and was discharged without any neurological sequelae., (© 2018 Wiley Periodicals, Inc.)

Background: The development of atrial fibrillation (AF) during the course of acute coronary syndrome (ACS) is related to poor prognosis. Possible predictors of new-onset AF (NOAF) have not been adequately investigated in elderly patients with ACS undergoing percutaneous coronary intervention (PCI). We aimed to identify the factors associated with NOAF in such patients., Methods: A total of 308 elderly patients with ACS undergoing PCI were enrolled in the study. Patients were divided into two groups: without NOAF [254 patients, 64.6% men, age: 73.5 (69.0-79.0) years] and with NOAF [54 patients, 70.4% men, age: 75.0 (68.7-81.2) years]. Clinical, angiographic, and laboratory features including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-high-density lipoprotein ratio (MHR) were compared between the groups., Results: The percentages of prior myocardial infarction (MI) (20.4 vs. 5.9%) and Killip III/ IV (24.1 vs. 7.1%), NLR [4.5 (2.6-7.2) vs. 3.2 (2.0-6.0)], and MHR [19.4 (15.7-26.5) vs. 12.9 (9.9-18.5)] were higher in patients with NOAF compared to the others (p = 0.020, < 0.001, 0.030, and < 0.001, respectively). In multivariate regression analysis, prior MI (OR 4.509, 95% CI 1.679-12.106, p = 0.003) and MHR (OR 1.102, 95% CI 1.054-1.152, p < 0.001) independently predicted NOAF. In addition, Killip III/IV was found to be an independent predictor of 6-month overall mortality (HR 2.949, 95% CI 1.218-7.136, p = 0.016)., Conclusions: Prior MI and MHR are independent predictors of NOAF in elderly patients with ACS undergoing PCI. Killip III/IV predicts 6-month overall mortality in such patients.

Contrast-induced nephropathy (CIN) is associated with worse prognosis in patients with acute coronary syndrome (ACS). Early identification and intervention for patients with a high risk of CIN are very important to improve clinical outcomes. Inflammation plays important role in the development of CIN in the setting of ACS. The monocyte to high-density lipoprotein ratio (MHR) is a novel inflammatory marker. Bleeding is also associated with worse prognosis in such patients. We aimed to investigate whether the preprocedural MHR had a predictive role for CIN development in such patients. In addition, using the thrombolysis in myocardial infarction classification, we aimed to assess whether there was any relationship between bleeding and CIN. A total of 647 patients (496 males; age: 63.3 ± 12.7 years) with ACS who underwent percutaneous coronary intervention (PCI) were included in the study. Seventy patients (10.8%) had developed CIN. Age, diabetes mellitus, contrast volume, estimated glomerular filtration rate, and MHR were independent predictors for CIN. Preprocedural MHR may be used as a simple marker of CIN. It may help with the early identification of patients with ACS who underwent PCI who are at high risk of CIN thus allowing the planning of protective measures.

Background: The aim was to evaluate the causes of thoracic endovascular aortic repair (TEVAR) failure and conversion to open surgery (COS) in a vascular center with high-volume open surgery and low-volume TEVAR procedures., Methods: A total of 8 patients (6 men; mean age, 55.14 years) underwent COS after TEVAR. The indications for COS, intraoperative strategy, and early postoperative and mid-follow-up results were analyzed., Results: The indications for COS were persistent proximal type I endoleak with progressive aneurysm enlargement in 2 patients, type III endoleak in 1 patient, progressive aneurysm enlargement with no endoleak in 1 patient, stent-graft migration in 2 patients, secondary aortoesophageal fistula in 1 patient, secondary aortoesophageal and aortobronchial fistula in 1 patient, and distal progression of the aneurysmal disease in 2 patients. In all but one patient, thoracic stent grafts were explanted, and replacement with a Dacron graft was performed using left partial cardiopulmonary bypass. In the remaining patients with disconnection of the distal component and unfavorable anatomy, the proximal stent graft was recycled, and the Dacron prosthesis was sewn to it. Patients with secondary aortobronchial and aortoesophageal fistulas required additional bronchial and esophageal repair. The in-hospital mortality rate was 50% (4 patients). Four (50%) patients were followed up between 7 and 24 months (mean, 16.75 months) without mortality., Conclusions: COS after TEVAR has a high mortality rate, and endovascular techniques should be considered as the first line of treatment. Those procedures should be performed by surgeons experienced in open repair which one might expect to be a challenging problem in the era of endovascular therapy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Clopidogrel inhibits platelet activation and aggregation by blocking the P2Y 12 receptor. Dual antiplatelet therapy with clopidogrel and aspirin is recommended treatment by current guidelines for patients undergoing percutaneous interventions. Recurrent ischaemic cardiac events after this treatment showed lack of clopidogrel responsiveness. We aimed to investigate the most noticeable variants in the genes involved in clopidogrel pharmacokinetics and pharmacodynamics. A total of 347 Turkish patients who underwent percutaneous coronary interventions with stent implantation were included in our study. Platelet reactivity (PRU) and % inhibition were measured with VerifyNow P2Y 12 assay in blood samples collected from patients who took a standard dose of clopidogrel (75 mg/day) for at least 7 days. The variants in the CYP2C19, CYP3A4, CYP2B6, ABCB1, ITGB3 and PON1 genes were genotyped using the Sequenom MassARRAY system. When grouped, the patients with PRU values >208 as non-responsiveness to clopidogrel therapy; 104 (30%) patients were non-responders and 243 (70%) patients were responders. A significant association was found between the CYP2C19*2 (G636A) polymorphism and non-responsiveness to clopidogrel therapy (p < 0.001). An allele frequency of this single nucleotide polymorphism was high in non-responders; its odds ratio was 2.92 compared with G allele (p < 0.001). PRU values of CT genotypes were lower (p = 0.029) and % inhibition values of CT genotypes were higher (p = 0.008) compared with CC genotypes for the CYP2C19*17 (C806T) polymorphism. None of the other genetic variants were found to be statistically associated with non-responsiveness to clopidogrel and antiplatelet activity. Our findings suggest that the CYP2C19*2 polymorphism is associated with non-responsiveness to clopidogrel therapy and the CYP2C19*17 polymorphism enhances antiplatelet activity of clopidogrel. Depending on haplotypes of these two polymorphisms, clopidogrel-treated patients can be protected or not from stent thrombosis and ischaemic events., (© 2017 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Objective: Aim of the present study was to determine effects of high-dose versus low-dose intravenous (IV) bolus tirofiban on angiographic measures, ST resolution, enzymatic infarct size, and clinical outcomes in patients with acute coronary syndrome (ACS) who were undergoing percutaneous coronary intervention (PCI) and received current pharmacoinvasive therapy., Methods: Acute coronary syndrome patients (n=271, 85.6% male; mean age: 57.9±12.6 years) from between 2009 and 2015 who received IV tirofiban therapy following PCI were retrospectively analyzed. All patients had received maintenance tirofiban infusion (0.15 µg/kg/min) after bolus dose and 600 mg clopidogrel. Percentage of patients undergoing drug eluting stent implantation procedure was 33.5%. Tirofiban was administered to all patients in bailout situation or for thrombotic complication after PCI., Results: High-dose IV bolus group (25 µg/kg; n=140) was associated with greater ST segment resolution (66% vs. 50%, p=0.013) and reduced peak troponin release [12.4 ng/dL (range: 6.5-21.5 ng/dL) vs. 16.4 ng/dL (range: 10.1-27.4 ng/dL), p=0.001] compared with low-dose bolus group (10 µg/kg, n=131). Cardiovascular event rates were similar between groups at in-hospital, 1-month, and 6-month follow-up (p=1.000, 1.000, and 0.287, respectively). Percentage of patients with post-procedural Thrombolysis in Myocardial Infarction (TIMI) grade III flow, major, and minor bleeding were similar (p=0.085, 1.000, and 0.965, respectively)., Conclusion: Use of high-dose IV bolus tirofiban in addition to aspirin and high-dose clopidogrel improves ST segment resolution, reduces infarct size, and does not increase bleeding events in patients with ACS undergoing PCI compared with low-dose bolus. Angiographic measures and clinical endpoints were similar between groups.

Inferior paraseptal accessory pathways (APs) have a wide distribution and prediction of AP location before radiofrequency ablation is very important in such pathways. We aimed to estimate successful ablation site based on electrocardiogram in 137 patients (mean age: 25.8±9.0; 126 males) with single manifest inferior paraseptal AP. Right endocardial inferior paraseptal APs were discriminated from left endocardial APs with an R/S ratio <1 (p<0.001) and negative delta wave in lead V1 (p<0.001). Epicardial inferior paraseptal APs were differentiated from endocardial APs by a negative delta wave in lead II (p=0.001), positive delta waves in AVR (p<0.001) and V1 (p=0.012), R/S ratio <1 in lead II (p=0.03), and R/S ratio ≥1 in V1 (p=0.04). Delta wave polarity and R/S ratio in lead V1 differentiate right endocardial inferior paraseptal APs from left endocardial APs. Delta wave polarities in leads II, AVR and V1, and R/S ratios in leads II and V1 estimate epicardial inferior paraseptal APs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Ivabradine is a heart rate (HR)-lowering agent acting by inhibiting the If-channel. Dobutamine does increase the HR and has some deleterious effects on myocardium. So, we aimed to evaluate whether ivabradine treatment blunts a dobutamine-induced increase in HR., Methods: The main study population consisted of 58 acute decompensated heart failure patients requiring inotropic support with left-ventricular ejection fraction below 35%, who were randomized to ivabradine (n = 29) or control (n = 29). All patients underwent Holter recording for 6 h and then dobutamine was administered at incremental doses of 5, 10 and 15 μg/kg/min, with 6-h steps. Holter recording was continued during dobutamine infusion. Ivabradine 7.5 mg was given at the initiation of dobutamine and readministered at 12 h of infusion. Also, a nonrandomized beta-blocker group with 15 patients receiving beta-blocker was included in the analysis. Control and beta-blocker groups did not receive ivabradine., Results: In the control group, mean HR gradually and significantly increased at each step of dobutamine infusion (81 ± 11, 90 ± 16, 97 ± 14 and 101 ± 16 b.p.m., respectively; P = 0.001), whereas no significant increase in HR was observed in the ivabradine group (82 ± 17, 82 ± 15, 85 ± 14 and 83 ± 12 b.p.m., respectively; P = 0.439). Mean HR was also found to significantly increase during dobutamine infusion in the beta-blocker group (75 ± 13, 82 ± 13, 86 ± 14 and 88 ± 13 b.p.m., respectively; P = 0.001). The median increase in HR from baseline was significantly higher in the control group compared to those in the ivabradine group (5 vs. 2 b.p.m.; P = 0.007 at first step, 13 vs. 5 b.p.m.; P = 0.001 at second step and 18 vs. 6 b.p.m.; P = 0.0001 at third step of dobutamine, respectively)., Conclusions: Ivabradine treatment prevents dobutamine-induced increase in HR and may be useful in reducing HR-related adverse effects of dobutamine.

Pregnancy is associated with an increased risk of valve thrombosis, hemorrhagic complications, and offspring complications in patients with metallic prosthetic heart valve (MHV). Warfarin treatment is the best regimen against thromboembolic complications, but its use in the first trimester can result in embryopathy. Low molecular weight heparin (LMWH) does not cross the placenta and has some potential advantages. However, the pharmacokinetics of LMWHs change during pregnancy, and serial monitoring of anti-Xa levels is strongly recommended. Despite this recommendation, LMWH therapy in a fixed dose is still used in pregnant women with MHV without monitoring anti-Xa activity in clinical practice. We present three cases of MHV thrombosis occurring while on therapy with LMWH during pregnancy. One of these patients showed cerebrovascular event, one presented with pulmonary edema, and one underwent reoperation for MHV thrombosis.

Objective: The objective of our study is to analyze whether low intraoperative hematocrit levels have an effect upon postoperative neurological events., Methods: Our study included 140 patients who underwent isolated coronary bypass under cardiopulmonary bypass between 2009 and 2012. The main group of the study was 70 patients with intraoperative hematocrit levels lower than 22%. These patients' 30-day postoperative neurological (particularly stroke) follow up was registered as the main data of the study. Another group of 70 patients possessing the same demographic features who underwent open heart surgery with hematocrit levels remaining above 22% were registered as the control group for perioperative neurological data., Results: The average age of the patients with hematocrit levels below and above 22% was 56.8 ± 5.8 years and 54.1 ± 7.3 years, respectively. The mean follow-up period of the patients was 37.2 ± 8.6 days. None of the patients had any neurological postoperative sequalae. No mortalities occurred. One patient who had mild paresthesia and motor weakness of the left hand had no pathological finding on computed tomography and was diagnosed with peripheral neuropathy due to intraoperative sternal retraction., Conclusion: Because our study revealed no cerebrovascular events, coronary bypass surgery under cardiopulmonary bypass may be safely conducted even in patients with hematocrit levels lower than 22%.

Objective: The aim of this retrospective multicenter study was to investigate the clinical manifestations, microbiological profile, echocardiographic findings and management strategies of infective endocarditis (IE) in Turkey., Methods: The study population consisted of 248 Turkish patients with IE treated at 13 major hospitals in Turkey from 2005 to 2012 retrospectively. All hospitals are tertiary referral centers, which receive patients from surrounding hospitals. Data were collected from the medical files of all patients hospitalized with IE diagnosed according to modified Duke Criteria., Results: One hundred thirty seven of the patients were males. Native valves were involved in 158 patients while in 75 participants there was prosthetic valve endocarditis. Vegetations were detected in 223 patients (89%) and 52 patients had multiple vegetations. Mitral valve was the most common site of vegetation (43%). The most common valvular pathology was mitral regurgitation. The most common predisposing factor was rheumatic valvular disease (28%). Positive culture rate was 65%. Staphylococci were the most frequent causative microorganisms isolated (29%) followed by enterococci (11%). In-hospital mortality rate was 33%., Conclusions: Compared to IE in developed countries younger age, higher prevalence of rheumatic heart disease, more frequent enterococci infection and higher rates of culture negativity were other important aspects of IE epidemiology in Turkey.

Clinical and electrophysiological features of different initiation patterns of ventricular tachycardia (VT) have been widely studied. At least two different onset patterns of VT have been defined in the studies. Tachycardias, which are preceded by either a single or multiple ventricular ectopic activity, including a short-long-short sequence, are defined as nonsudden onset and those, which are not preceded by ventricular ectopy are defined as sudden onset. The knowledge of initiation pattern of VTs may have some clinical importance and can be essential for the selection of treatment strategies. The use of Holter electrocardiograms and analysis of intracardiac electrograms from implantable cardioverter-defibrillators enables to evaluate the initiation patterns of VTs., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Aim: Pseudoexfoliation (PEX) syndrome, diagnosed by ocular examination, is a common disorder of the extracellular matrix. Previous studies have demonstrated accumulation of PEX material in the walls of blood vessels and myocardium. We aimed to investigate whether PEX is associated with cardiovascular involvement using carotid ultrasound measurements and myocardial tissue Doppler imaging (TDI)., Methods: Thirty-six PEX patients and 34 age-matched and sex-matched healthy controls who had no PEX material were included. Fasting blood samples were taken and the following data were obtained from all cases: myocardial TDI measurements, the mean carotid intima-media thickness (IMT), total carotid plaque area and number., Results: There were no significant differences between the groups regarding clinical and biochemical data. The peak systolic TDI velocities at the septal (septal S) and lateral annuli (lateral S), and the isovolumic contraction velocity at the lateral annulus [lateral isovolumic contraction velocity (IVC)] were significantly lower in patients with PEX, than in controls (P = 0.001, <0.001 and 0.016, respectively) whereas IMT, total carotid plaque area and number were significantly higher (P = 0.002, 0.035 and 0.033, respectively). In a logistic regression analysis including age, septal S, lateral S, lateral IVC, IMT, total carotid plaque area and number, septal S, lateral S and IMT were significantly associated with PEX, (P = 0.035, 0.011 and 0.035, respectively)., Conclusion: Peak systolic TDI velocities were significantly lower and IMT was significantly increased in patients with PEX. However, PEX was weakly associated with carotid plaque measurements.

Anthracyclines can cause severe cardiac toxicity leading to heart failure. The aim of this study was to determine the effects of cardioprotective polyphenolic compound resveratrol (RES) and adipose-derived mesenchymal stem cells (ADMSCs) on cardiac tissue of rats treated with doxorubicin (DOX). Forty-two female and three male Wistar-Albino rats were included in the study. The study groups and the control groups were as follows: Group I: DOX; Group II: DOX + RES; Group III: DOX + ADMSCs; Group IV: DOX + RES + ADMSCs; Group V: Sham operation; and Group VI: normal saline. ADMSCs obtained from male rats were defined with stem cell markers [CD11b/c(-), CD45(-), CD90(+), CD44(+), and CD49(+)]. DOX 12 mg/kg intraperitoneally (i.p.) was injected as a single dose in female rats. Resveratrol 100 mg/kg was injected three times i.p. in Groups II and IV. ADMSCs 2 × 10(6) cells/kg/dose were labeled with bromodeoxyuridine (BrdU) and injected i.p. for a total of three times in Groups III and IV. When the study was terminated after 4 weeks, the beating hearts were connected to a Langendorff setup and records were obtained for 30 minutes. Histopathological, immunhistochemical, and immunofluorescent examination with H&E, Troponin I, and BrdU stains were also performed. Also, ADMSCs were demonstrated in the myocardium of transplanted rats. Left ventricle functions and myocardial histology demonstrated significant impairment in DOX only group compared to groups with ADMSCs (P < .05). We suggest that RES and ADMSCs were successful in the prevention and treatment of the doxorubicin cardiomyopathy in rats. The hypothetical mechanisms of regeneration are multiple, including cell differentiation and autocrine/paracrine effects of ADMSCs.

Objectives: The frequency of hypoplastic right coronary artery (HRCA) and its contribution to coronary artery anomalies (CAAs) has not been thoroughly studied. Here we aimed to investigate whether a casual relationship exists between the presence of HRCA and CAAs., Materials and Methods: We retrospectively reviewed coronary angiography records of 7500 patients. The images were carefully assessed for coronary artery (CA) anatomy and CAAs. Overall, we compared CAAs at the presence and absence of HRCA and evaluated potential association between HRCA and CAAs. Besides, we grouped HRCA patients according to the presence of CA disease (CAD) into two groups and compared their CAAs., Results: While the percentage of HRCA was 6.2%, it was 3.34% for CAAs. The percentage of CA with anomalous origin (CAAO) at the presence of HRCA was significantly higher than the presence of normal right coronary artery (NRCA) (p < 0.01). Similarly, the percentage of absent left main coronary artery (ALMCA) was also considerable increased in HRCA patients with respect to the patients with NRCA (p < 0.01). The percentage of CAAO was notably higher in the CAD (-) than CAD (+) patients with HRCA (p < 0.01). Likewise, the prevalence of ALMCA was also noticeably higher in the CAD (-) than CAD (+) patients with HRCA (p < 0.01)., Conclusions: HRCA is a clinically significant and frequently encountered congenital variation. The present observations indicate that the presence of HRCA is closely associated with a high prevalence of CAAO, particularly with increased rate of ALMCA.

Radiofrequency (RF) catheter ablation is a treatment of choice widely used for a variety of supraventricular tachycardia. Transient sinus and atrioventricular (AV) node dysfunctions may occur during RF application to sites remote from the sinus and AV nodes, but they generally resolve quickly after cessation of RF current. We present a case of two episodes of asystole in a 43-year-old man induced by RF catheter ablation of an AV nodal slow pathway. A Bezold-Jarisch-like reflex, direct stimulation of parasympathetic fibers traveling to the sinus and AV nodes, RF-induced myocardial injury or pain could be responsible for this situation., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Cardiac simulators have been developed as an alternative training model in order to improve the cardiac auscultation skills of medical students. The effectiveness of the cardiac simulator's use in cardiac auscultatory training is presently not yet well established., Objectives: The authors aimed to investigate whether the use of a cardiac simulator can improve the auscultation skills of medical students., Material and Methods: The students taking the auscultation training on the cardiac simulator were grouped as Group A and the students not taking the auscultation training on the cardiac simulator were grouped as Group B (before). The students in Group B (before) were grouped as Group B (after) after receiving the auscultation training on the cardiac simulator. The percentages of accurate diagnoses for the tested heart murmurs were compared between Group A and Group B (before), and between Group B (before) and Group B (after)., Results: The rate of making correct diagnoses of normal heart sounds was similar in all the groups (Group A, Group B (before), and Group B (after)). By contrast, the percentage of accurate diagnoses for the tested heart murmurs was notably improved among the students in Group A with respect to Group B (before) (p < 0.01). Similarly, the rate of correct diagnoses for the tested heart murmurs was markedly higher among the students in Group B (after) than in Group B (before) (p < 0.01)., Conclusions: The use of a cardiac simulator as a training tool can improve the auscultation skills of medical students quickly and efficiently.

Aim: To compare the quality of the 2008 cancer mortality data of the Istanbul Directorate of Cemeteries (IDC) with the 2008 data of International Agency for Research on Cancer (IARC) and Turkish Statistical Institute (TUIK), and discuss the suitability of using this databank for estimations of cancer mortality in the future., Methods: We used 2008 and 2010 death records of the IDC and compared it to TUIK and IARC data., Results: According to the WHO statistics, in Turkey in 2008 there were 67255 estimated cancer deaths. As the population of Turkey was 71517100, the cancer mortality rate was 9.4 per 10000. According to the IDC statistics, the cancer mortality rate in Istanbul in 2008 was 5.97 per 10000., Conclusion: IDC estimates were higher than WHO probably because WHO bases its estimates on a sample group and because of the restrictions of IDC data collection method. Death certificates could be a reliable and accurate data source for mortality statistics if the problems of data collection are solved.

There has been a significant increase in the cases of skin cancer throughout the world in the last few decades. Although the mortality rate of skin cancer is relatively low, its impact on other health aspects is high and the treatment of undesired aesthetic damage is costly. According to disability-adjusted life year rates (DALY), 1.5 million days are estimated to be lost from people's lives every year worldwide due to ultraviolet (UV) radiation. The purpose of this study was to raise sun health awareness levels among health services vocational school students. A total of 414 students were included in the analysis. A questionnaire form was used to evaluate knowledge, attitudes and behaviours among the survey sample. The average level of knowledge concerning the effects of the sun was found to be 8.64 ± 2.5 out of 15 points. All socio-demographic factors were analysed, but the only significant variables found were age and the possible presence of skin cancer within the immediate family (p < 0.05).

The purpose of this study was to evaluate smoking prevalence and factors associated with smoking among students at the Physical Education and Sports School of Istanbul University. A cross-sectional study was performed on total of 373 students who have been continuing their education at the school from February to March 2011. A total of 166 responders were male (44.5%) and 207 responders were female (55.5%) out of 373 participants. Of the 373 students, 94 (25.2%) were current smokers and the average age for beginning smoking was 18.03 ± 2.6 (min: 12-max: 30). In this study, we found that the smoking prevalence associated with some variables such as age place of residence, mother's education, father's education, cigarette or tobacco use in the living place, knowledge status of students about their teacher's smoking habits and alcohol consumption (p ≤ 0.05). These findings suggest that the students, who will train the sportspeople of the future, and should be considered a role model of healthy behavior in society. Consequently, we believe that sports school students should take an active role in providing health education programs to increase their awareness about the detrimental effects of smoking and to extensively quit smoking in public.

Objective: Previous studies in hypercholesterolemic patients with coronary artery disease (CAD) have demonstrated that lipid lowering therapy restores coronary endothelium dependent vasodilatation and increases myocardial perfusion. However, there is not enough data showing the effects of statins on myocardial perfusion in metabolic syndrome (MetS) patients who have perfusion abnormalities but not evident CAD, which are attributed to microvascular dysfunction. We aimed to evaluate whether or not statin therapy improves myocardial perfusion, as assessed by Technetium (Tc)-99m single-photon emission computed tomography (SPECT), in patients with MetS and angiographically normal epicardial coronary anatomy., Materials and Methods: The study population consisted of 55 selected patients (mean age: 52, 72% female) with MetS who have perfusion defect on exercise stress Tc-99m SPECT and normal coronary arteries. Patients were treated with 20 mg atorvastatin for six months regardless of baseline lipid levels and SPECT study was repeated after the therapy. The summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS), and left ventricular (LV) volumes and ejection fractions (EF) at rest and stress were obtained., Results: We found significant improvements in SSS, SRS and SDS after six months of statin therapy (p = 0.001, 0.001 and 0.002, respectively). In addition, end-diastolic volumes at rest and stress, and stroke volume at rest were significantly decreased (p = 0.001, 0.001 and 0.026, respectively). Also, LV EF at stress was significantly increased (p = 0.035)., Conclusions: Statin therapy in patients with MetS who have perfusion defects on Tc-99m SPECT and normal coronary arteries produces significant improvements in myocardial perfusion abnormalities.

The coarctation of the aorta (CoA) is one of the most frequently encountered congenital heart diseases and in most of cases it is characterized with a discrete narrowing localized on the thoracic aorta just distal to the left subclavian artery. The incidence of totally occluded CoA is very rare. The treatment options for CoA include surgical approaches, transcatheter balloon angioplasty, or stent placement. Although stenting has been the preferred method for the treatment of CoA, few studies exist in the literature regarding the use of stenting approach in the treatment of total occluded CoA. Therefore, we aimed to present a CoA patient treated using material and techniques used in the standard treatment of chronic total occlusion of coronary arteries.

Intracardiac involvement rarely develops in patients with hepatocellular carcinoma (HCC) and its prognosis is poor. Patients generally have symptoms of sudden dyspnea or massive lower extremity edema and the clinical course may be further complicated by many fatal cardiovascular complications. Absence of cardiac symptoms or findings, however, is an unusual condition. We present a 61-year-old man with HCC who was incidentally found to have an intracavitary mass completely occupying the right atrium. He had no cardiac complaints, nor any signs of cardiac involvement. The mass was first detected by computed tomography and then confirmed by transthoracic echocardiography. The patient underwent a successful surgical resection and the histopathologic diagnosis was HCC. Unfortunately, the postoperative course was complicated by the development of acute kidney failure and, despite hemodialysis treatment, the patient died of kidney failure eight days after the operation.

Coronary artery anomalies are rarely encountered in general population. Gender may play a role in the types and incidence of coronary artery anomalies, although the effect of gender is not well established. In the present study, we therefore aimed to investigate the frequency and location of various types of coronary artery anomalies and their correlation with gender. We assessed retrospectively the coronary angiography movies of 7,810 patients (2,214 females and 5,596 males), the method of which is distinct from the earlier studies with angiographic archive records. We defined and classified the coronary artery anomalies according to their origin, course (myocardial bridge), and termination (fistula). The incidence of coronary artery anomalies was 3.35% (262 of 7,810): 130 individuals with anomalous origin (1.66%), 105 individuals with myocardial bridges (1.34%), and 27 with fistulas (0.35%). The frequency of the coronary artery anomalies was significantly higher in the females than the males (p = 0.001). Of the coronary artery origin anomalies, the circumflex and the left anterior descending artery originating from separate ostia in the left aortic sinus were higher in the females compared to the males (P < 0.001). In contrast, the frequency of myocardial bridges was higher in the males (P = 0.01). No gender difference was detected in fistulas. Thus, gender affects the types of coronary artery anomalies, except for fistulas. The determination of the presence of the coronary artery anomalies during the coronary angiography is critical for the planning of the treatment and for the proper clinical follow-up of patients.

The full diagnostic potential of the fractal complexity measure, α, of detrended fluctuation analysis (DFA) has not been realized yet. To reveal the impaired mechanisms in the blood flow regulation in patients with essential hypertension (EHT), we studied the laser Doppler flowmetry (LDF) time series by applying DFA. Forearm microvascular blood flow was measured by LDF during supine rest. After a 15 min baseline recording, microvascular response to thermal hyperemia was measured over 30 min. We found three distinct scaling regions; corresponding to the integration of local mechanisms, cardiac effect on local blood flow, and the coupling of extrinsic factors (cardiac and respiratory) to local blood flow by myogenic mechanism. In the control group, local scaling exponent, α(L)=0.96 ± 0.08, did not change but cardiac scaling exponent, α(C)=1.53 ± 0.05, for baseline signal was increased to α(CT)=1.73 ± 0.10 and cardio-respiratory scaling exponent, α(CR)=0.73 ± 0.19, was decreased to α(CRT)=0.24 ± 0.06 during vasodilatation in response to local heating. However, we found significantly different scaling exponents, α(LT)<1, α(CT) ≥ α(C)<1.5 and α(CR) ≈ α(CRT)>0.5 in patients with EHT. Our findings suggest that the local regulatory and the cushioning peripheral vascular functions are impaired in patients with EHT, and vascular/microvascular pathology can be evaluated by applying DFA to LDF signal., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Intercoronary continuity refers to a bidirectional flow in patients with normal coronary arteries. Although such connections have been proposed to have a protective role against potential obstructive coronary artery disease, their functional significance is unclear. We report on a 53-year-old woman who presented with typical chest pain. Exercise myocardial perfusion imaging revealed perfusion defects involving the basal regions of the inferior and inferoseptal walls. Coronary angiography showed an intercoronary continuity between the right coronary artery and circumflex artery. Following institution of medical therapy, the patient's complaint improved and she had no complaint during one-year follow-up. This is the first reported case in which an intercoronary continuity was associated with myocardial ischemia.

Objective: To determine the knowledge, attitude, and opinion of private school principals in Kocaeli, Turkey regarding substance abuse., Methods: Data of this descriptive study was collected by questionnaires in December 2008. The questionnaire, developed based on Turkey's "substance abuse regulations," was applied to the principals of private schools in Kocaeli affiliated with the Ministry of National Education. A survey was conducted and risk factors for these schools were determined. The data was analysed with Pearson correlation test, Spearmen correlation test and Kruskal-Wallis one way analysis used., Results: Principals of 27 of 31 schools were reached. Six (22.2 %) were women; 21 (77.8 %) were men. Average age was 43.37 +/- 10.08 years. Average years of teaching was 21.55 +/- 10.77 years. Mean period as a school principal was 9.42 +/- 9.36 years. Seventy-one percent of the principals who participated in the survey were non-smokers., Conclusion: The majority of principals considered substance abuse as a problem in Turkey and believed it to be more among primary and high school students.

Purpose: Pseudoexfoliation (PEX) syndrome is characterized by the widespread deposition of abnormal extracellular fibrillary material on many ocular and extraocular tissues. We aimed to investigate the association between PEX syndrome and subclinical myocardial ischaemia, using tissue Doppler echocardiography., Methods: Thirty-two patients with pseudoexfoliation syndrome (mean age: 66±9 years, 22 men) and 25 healthy individuals (mean age: 67±8 years, 13 men) were included in the study. Patients with overt coronary artery disease, congestive heart failure, valvular heart disease, cardiomyopathy, and left ventricular hypertrophy were excluded from the study. Tissue Doppler imaging was performed at the septal, lateral, anterior, and inferior mitral annuluses. Differences between the groups were evaluated by the unpaired t-test and the Mann-Whitney U-test, with a P-value of <0.05 considered significant., Results: Baseline clinical characteristics, two-dimensional, and Doppler echocardiography parameters were similar in the PEX and control groups. Peak systolic velocities at the septal, lateral, anterior, and inferior annuluses were significantly lower in patients with PEX syndrome (P<0.001, 0.01, 0.02, and 0.02, respectively). The early diastolic velocity at the septal annulus, and the ratio of early/late diastolic velocity at the lateral annulus were significantly lower in the study group (P=0.03)., Conclusion: PEX syndrome is a common disorder of extracellular matrix. Our data suggest that there may also be an association between PEX syndrome and subclinical myocardial ischaemia in patients who have no signs and symptoms of ischaemia. Thus, we think that ophthalmologists should consider informing their PEX syndrome patients' general practitioners about a possible cardiac risk.

Objectives: Accumulating data indicate that serum gamma-glutamyltransferase (GGT) activity represents a true marker of atherosclerotic cardiovascular disease and has prognostic importance. In this study, we sought to evaluate serum GGT activity in patients with metabolic syndrome (MetS)., Study Design: We enrolled 232 patients (mean age 60.4 years) from our outpatient cardiology clinic, 117 with and 115 without MetS (control group) as defined by the ATP-III criteria. The results of serum liver function tests including serum GGT and C-reactive protein (CRP) levels were compared between the two groups., Results: The two groups were similar with regard to age, sex, smoking, and family history of coronary artery disease (p>0.05). The prevalences of hypertension and dyslipidemia were significantly higher in patients with MetS. Compared with controls, patients with MetS had significantly higher serum GGT [(median 21, interquartile range (16-33) vs. 19 (14-26) U/l; p=0.008] and C-reactive protein levels [6.2 (3.6-9.4) vs. 5.0 (3.1-7.0) U/l; p=0.044]. A high GGT activity (>40 U/l) was determined in 14.5% of the patients with MetS and in 4.4% of the control subjects (p=0.012). Serum GGT level showed significant correlations with MetS (r=0.24, p=0.001), CRP (r=0.20, p=0.003), triglyceride (r=0.18, p=0.006), HDL cholesterol (r=-0.19, p=0.004), aspartate aminotransferase (r=0.15, p=0.02), alanine aminotransferase (r=0.32, p=0.001), and alkaline phosphatase (r=0.16, p=0.01). This significant association continued only for MetS (β=-0.25, p=0.03), HDL cholesterol (β=-0.18, p=0.03), and alkaline phosphatase (β=0.17, p=0.01) in multivariate regression analysis., Conclusion: Our findings suggest that patients with MetS have higher serum GGT and CRP levels compared with controls. This increased GGT level might be a marker of increased oxidative stress and premature atherosclerosis.