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A 22-year old boy was diagnosed arrhythmogenic right ventricular dysplasia (ARVD) with bicuspid aortic valve (BAV) after a symptomatic event of ventricular tachycardia originating from the right ventricle. Cardiac magnetic resonance imaging disclosed right ventricular enlargement, diffuse thinning of lateral wall and normal left ventricle. Echocardiography showed globally thinned, moderately enlarged right ventricle and bicuspid aortic valve. Cardiovascular malformations may be present with bicuspid aortic valve. Here we would like to report the first ARVD case with an accompanying BAV., Sa¤ ventrikül kaynakl› ventriküler taflikardiye ba¤l› semptomu olan 22 yafl›nda erkek bir hastada aritmojenik sa¤ ventrikül displaziye (ASVD) efllik eden bikuspit aortik kapak (BAK) saptad›k. Kardiyak manyetik rezonans görüntülemede sa¤ ventrikül lateral duvarda yayg›n incelme ile geniflleme ve normal sol ventrikül saptand›. Ekokardiyografide ise sa¤ ventrikülde orta derece geniflleme ile global incelme ve BAK saptad›k. Bikuspit aortik kapak di- ¤er kardiyovasküler malformasyon ile birlikte bulunabilmektedir. Biz bu yaz›m›zda ilk defa ASVD'ye efllik eden BAK olgusunu bildirdik.

Objective: Although several hypotheses have been suggested, the underlying mechanism of coronary slow flow phenomenon (CSFP) has not been well established yet. The aim of this study was to determine the roles of plasma apolipoprotein-B100 (Apo-B) and apolipoprotein-A1 (Apo-A1) in CSFP which have an atherogenic effect and anti-atherogenic effects respectively. Methods: The study consisted of 31 patients with CSFP (group 1), 28 normal subjects as control group (group 2) and 30 patients with coronary artery disease (CAD) (group 3) detected by coronary angiography. CSFP was diagnosed by the TIMI frame count method. Blood Apo-B, Apo-A1, Apo-B/Apo-A1 ratio, and demographic parameters were compared between the groups. Results: The Apo-B values were 93±25 mg/dL, 90±26 mg/dL, and 106±27 mg/dL in groups 1, 2 and 3, respectively (p=0.048 between group 1 and 3, p=0.041 between group 2 and 3, p= NS between group 1 and 2). The Apo-A1values were 127±14 mg/dL, 125±21 mg/dL and 106±27 mg/dL in groups 1, 2 and 3 respectively (p=0.028 between group 1 and 3, p=0.021 between group 2 and 3, p= NS between group 1 and 2). The apo- B/apo-A1 ratio were 0.73±0.18, 0.69±0.23 and 0.98±0.20 in groups 1, 2 and 3 respectively (p=0.017 between group 1 and 3, p=0.010 between group 2 and 3, p= NS between group 1 and 2). Conclusion: Although lower levels of plasma Apo-A1 and higher levels of Apo-B and the ratio of Apo-B to Apo-A1 are related with CAD, there is no relationship between these apolipoproteins and CSFP., Amaç: Koroner yavafl ak›m fenomenin (KYAF) altta yatan mekanizmas› henüz tam olarak tan›mlanmam›fl olmas› na ra¤men çeflitli hipotezler ileri sürülmüfltür. Bu çal›flmam›z da s›ras›yla aterojenik ve anti-aterojenik etki gösteren plazma apolipoprotein-B100 (Apo-B) ve apolipoprotein-A1'in (Apo-A1) KYAF'deki rolünü araflt›rd›k. Yöntemler: Çal›flmaya koroner anjiografik olarak KYAF'si olan 31 hasta (grup 1) ile normal kiflilerden oluflan 28 kontrol grubu (grup 2) ve koroner arter hastal›¤› olan 30 hasta (grup 3) al›nd›. KYAF tan›s› TIMI kare say›s› yöntemiyle kondu. Gruplar›n plazma Apo-B, Apo-A1, Apo-B/Apo-A1 oran› ve demografik özellikleri karfl›laflt›r›ld›. Bulgular: Grup 1, 2 ve 3'deki ortalama Apo-B de¤erlerini s›ras›yla 93±25 mg/dL, 90±26 mg/dL, 106±27 mg/dL olarak saptad›k (grup 1 ile 3 aras›ndaki p=0.048, grup 2 ile 3 aras›ndaki p=0.041, grup 1 ile 2 aras›ndaki p= AD). Grup 1, 2 ve 3'deki ortalama Apo-A1 de¤erlerini s›ras›yla 127±14 mg/dL, 125±21 mg/dL, 106±27 mg/dL olarak saptad›k (grup 1 ile 3 aras›ndaki p=0.028, grup 2 ile 3 aras›ndaki p=0.021, grup 1 ile 2 aras›ndaki p= AD). Grup 1, 2 ve 3'deki Apo-B/Apo-A1 oran›n› ise s›ras›yla 0.73±0.18, 0.69±0.23 ve 0.98±0.20 olarak saptad›k (grup1 ile 3 aras›ndaki p=0.017, grup 2 ile 3 aras›ndaki p=0.010, grup 1 ile 2 aras›ndaki p= AD). Sonuç: Koroner arter hastal›¤› düflük plazma Apo-A1 düzeyi ile yüksek plazma Apo-B düzeyi ve Apo-B/Apo- A1 oran› ile iliflkilendirilmifl olmas›na ra¤men apolipoproteinler ile KYAF aras›nda bu iliflki bulunmam›flt›r.

Patent ductus arteriosus is a congenital heart disease which can cause chronic volume overload leading to congestive heart failure. A 34-year-old woman with rest dyspnea was found to have patent ductus arteriosus and echocardiogram revealed a markedly dilated left ventricle (8.9 cm) and severely-compromised left ventricle systolic functions (ejection fraction~24%). The patent ductus arteriosus was successfully closed percutaneously with Amplatzer occluder device. The patient was discharged on optimal dosages of ramipril, metoprolol, furosemide, spiranolactone and aspirin. On the follow-up after 18 months, the symptoms were found to have regressed and echocardiographic parameters improved (ejection fraction~55%)., Konjenital bir kalp hastal›¤› olan patent duktus arteriyozus (PDA) kronik volüm yüküne ba¤l› olarak konjestif kalp yetersizli¤ine neden olabilmektedir. 34 yafl›nda istirahatde nefes darl›¤› olan bir kad›n hastada PDA ile ekokardiyografik olarak ileri derece dilate solventrikül (8.9 cm) ve bozulmufl sol ventrikül sistolik fonksiyonu saptad›k (ejeksiyon fraksiyon~24%). Patent duktus arteriyozus Amplatzer t›kay›c› alet ile baflar›l› bir flekilde kapat›ld›. Hasta optimum doz ramipril, metoprolol, furosemide, spiranolactone ve aspirin tedavisi ile taburcu edildi. 18 ayl›k takip sonucunda semptomlarda gerileme ve ekokardiyografik parametrelerde düzelme saptand›.

Figure 1. (A) The twisted end got (arrowhead) caught at the tip of the sheath (arrows). (B) The snare (dotted arrow) was used to catch the tip of broken catheter in the arch of aorta. (C, D) The twisted end (arrowheads) was untwisted counterclockwise first in order not to damage the vasculature while being pulled out, Push What Won’t Proceed Girişimsel Kardiyolojide Temel Kural: Gitmiyorsa İtme, Gelmiyorsa Çekme Soe Moe Aung2, Ahmet Güler1, Can Yücel Karabay1, Yeliz Güler1, Cevat Kırma1 1Kartal Koşuyolu Training and Research Hospital, Clinic of Cardiology, İstanbul, Turkey 2Fatih University Faculty of Medicine Hospital, Clinic of Cardiology, İstanbul, Turkey

Objectives: The coronary slow flow phenomenon (CSFP), characterized by decreased distal progression of dye to coronary arteries, is a distinct angiographic phenomenon and little is known about its pathophysiology. Although several hypotheses have been suggested, the underlying mechanism of CSFP has not been well established yet. The aim of this study was to determine the roles of indicators of dehydration and haemoconcentration in CSFP which have blood flow abnormality effects. Methods: The study consisted of 33 patients with CSFP (group 1), and 31 normal subjects as control group (group 2) detected by coronary angiography. CSFP was diagnosed by the TIMI frame count method. Serum electrolytes, osmolarity and haematological parameters were measured. Results: Compared with control subjects, patient with CSFP had increased levels of calculated osmolarity, tonicity, sodium, glucose and blood urea nitrogen (BUN). Significant differences were also observed in the haematocrit, haemoglobin concentration, and calculated osmolarity but not in total cholesterol and albumin. Conclusions: The results of the present study indicate that the markers of haemoconcentration and dehydration are significantly associated with CSFP. The markers may be important in the coronary blood flow anomaly., Amaç: Patofizyolojik olarak az bilinen koroner yavafl ak›m fenomeni (KYAF) distal koroner arterin boyanma h›z›n›n azalmas› ile karekterize anjiografik bir fenomendir. Çeflitli hipotezler ileri sürülmüfl olsada KYAF'nin mekanizmas› tam olarak aç›klanmam›flt›r. Bu çal›flman›n amac› dehitratasyon ve hemokonsantrasyon belirteçlerinin KYAF'de kan ak›m anomalisindeki rolünü belirlemektir. Yöntemler: Çal›flmaya anjiografik olarak 33 KYAF'si olan hasta (grup 1) ile 31 normal olan kontrol grubu hasta al›nm›flt›r. KYAF tan›s› TIMI frame say›m metodu ile konmufltur. Serum elektrolit, osmolarite, ve hematolojik parametreler ölçülmüfltür. Bulgular: KYAF hastalar›nda kontrol grubuna göre hesaplanm›fl osmolarite, tonisite, sodyum, glukoz, ve kan üre nitrojen düzeyi daha yüksek saptanm›flt›r. Ayr›ca total kolesterol, albumin hariç hematokrit, hemoglobin ve hesaplanm› fl osmolarite de anlaml› fark saptanm›flt›r. Sonuç: Bu çal›flmam›z KYAF ile hemokonsantrasyon ve dehitratasyon belirteçlerinin anlaml› olarak iliflkili oldu¤unu göstermifltir. Bu belirteçler koroner kan ak›m anomalisinde önemli olabilir.

Acute mesenteric ischemia (AMI) is an uncommon disorder with serious morbidity and mortality caused by acute obstruction of the intestinal vessels. The obstruction is generally due to cardiac thromboembolism or, less frequently, by the acute thrombosis on an existing atherosclerotic plaque. The most commonly involved vessel is the superior mesenteric artery (SMA).Surgical revascularization and resection is still the treatment of choice. Although percutaneous transluminal revascularization has been found to be as effective as surgical revascularization in chronic mesenteric ischemia, there is not enough evidence in literature for its use in acute cases. A 70-year-old female patient presented to our emergency department with an ongoing abdominal pain of 12-hour duration, nausea, vomiting and palpitation. She had a previous medical history of cerebrovascular accident (CVA), hypertension, chronic obstructive pulmonary disease, type 2 diabetes mellitus and atrial fibrillation (AF). She was under treatment with aspirin and warfarin for CVA and AF. On physical examination, the blood pressure was 80/50 mmHg and pulse rate 142 per minute. The heart sounds were normal and rhonchus was heard over bilateral lungs fields. The abdomen was tender and rebound pain was present. ECG was normal except for AF with high ventricular response. Laboratory results showed normal values of ALT, AST, amylase, lipase and troponin I, but leukocyte count and CRP were high (leukocyte: 20200/mm3, CRP: 237 mg/L). Her INR was 2.4. On abdominal computed tomography, diffuse increased wall thickness of the ileum and mesenteric edema were seen, and acute mesenteric ischemia was confirmed. Because of the patient’s clinical conditions, accompanying systemic diseases and the extended ischemia of the intestines, surgical mortality was considered very high. Percutaneous transluminal angioplasty was contemplated as is carried out in acute myocardial infarction. After obtaining written informed consent from the patient, celiac angiography was performed via the right femoral artery approach. A 100% occlusion was seen in the proximal SMA (Figure 1). Right Judkins catheter was used to engage the ostium of the SMA. The total occlusion was crossed with the floppy guide wire. After predilatation with a 2.75×30 mm balloon, two bare metal coronary stents of 4.5×24 mm and 4.5×20 mm were implanted end to end at 18 atm (Figure 2). A good distal flow was achieved (Figure 3). In addition to antibiotic and antiarrhythmic medications, heparin infusion was started. Clopidogrel loading and maintenance doses of 600 mg and 75 mg and acetyl salicylic acid 300 mg were also prescribed. Abdominal pain began to subside dramatically after the procedure and disappeared completely after one week. At the two-month follow-up, the intestinal functions have recovered and tomography taken at the 3-month follow-up showed that the SMA was patent and the thickness of the intestinal wall had returned to normal. Figure 1. Totally occluded superior mesenteric artery Figure 2. Implanting the stent Figure 3. Superior mesenteric artery angiogram after stenting Acute mesenteric ischemia is a rare disorder with serious morbidity and mortality caused by acute obstruction of the intestinal vessels. The obstruction is generally due to cardiac thromboembolism or, less frequently, by acute thrombosis on an existing atherosclerotic plaque. Although abdominal pain is severe in the early phase, tenderness is typically absent on initial physical examination. With ongoing ischemia and intestinal tissue damage, tenderness appears. Thus, the diagnosis is often made late. As ischemia has already occurred by the time of diagnosis, the treatment of choice is surgery, and the resection of the bowels is often inevitable. Successful angioplasty or stenting of mesenteric artery in the absence of intestinal necrosis have been reported in literature (1, 2). Percutaneous transluminal angioplasty has been found to be as effective as surgical treatment (3, 4). However, in acute cases, timely diagnosis and revascularization before necrosis is often impossible. As a result, stenting of acute occlusion is not widespread. In the literature, only a few cases of early diagnosis with successful thrombectomy and angioplasty have been reported (5–7). In our patient, the diagnosis was made early and successful angioplasty and stenting was carried out because of severe comorbidity. In short, mesenteric ischemia has high morbidity and mortality despite treatment. Primary angioplasty and stenting before intestinal necrosis may be life-saving, especially in patients at high surgical risk.

Giriş ve amaç:Obstrüktif uyku apne sendromu (OSAS), kardiyovasküler hastalıkları ile ilişkilidir. Son yıllarda çok sayıda çalışmada bu ilişkiyi araştırılmıştır. Çalışmamızda obstruktif uyku apne sendromu ile aort çapı arasındaki ilişkiyi araştırmayı amaçladık.Materyal ve metod:Göğüs hastalıkları kliniğine OSAS semptomlarıile başvuran42'si erkek, 11'i kadın toplamda 53 hasta, OSAS tanısı kesinleştirmek için yapılan polisomnografi sonucunda 40 hastada OSAS olduğu,13 hastanın ise normal olduğu tespit edilmiştir. Bu sonuca göre hastalar OSAS ve kontrol olarak iki gruba ayrılmıştır. Her iki grupta da daha önce bilinen aort hastalığı öyküsü yoktur. Tüm hastalara ekokardiyografi yapılarak aort çapının dört ayrı yerden ( annular, sinüs valsalva, sinutubuler bileşkesi ve asendan aort) kaydedildi. Her hasta için yaş, cinsiyet ve BMI değerine göre normal aort referns değerlerine aort genişliği araştırılmıştır. İki grup arasındaki Veriler karşılaştırıldı. Verilerin karşılaştırmasında Mann Whitney U testi kullanıldı. Normal dağılım gösteren parametrelerin niteliksel verilerin karşılaştırılmasında Ki-Kare testi kullanıldı. Normal dağılıma uygunluk gösteren parametreler arasındaki ilişkilerin incelemesinde Pearson korelasyon analizi kullanıldı.Bulgular: Sinütubuler bileşkesinin ve asendan aort çapı OSAS grubunda anlamlı olarak daha yüksek saptandı (p or = 5/hour. 40 patients had OSA, 13 patients were normal. Aortic Diameter was calculated by Echocardiograpy within annular, sinus valsalva, sinotublar junction and ascendan Aorta. Aorta diameter was reffered for normal values for every patient related to sex, age, and BMI. Data from two groups were compared.RESULTS:The diameter of sinotubular junction and ascendan aorta was significantly high in OSA group compared with normal group (