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Background: Hydralazine-nitrate combination is recommended for patients with heart failure with reduced ejection fraction (HFrEF)/systolic heart failure who are symptomatic despite guideline-directed medical therapy (GDMT). Use of nitrates alone for this indication is not well-established. This study aims to evaluate the effect of oral nitrates on all-cause mortality and hospitalization in HFrEF patients using GDMT.Methods and Results: Nitrate prescription at discharge and its association with all-cause mortality and heart failure hospitalization were examined in a propensity-matched analysis of 648 HFrEF patients followed for a median of 56 months. A total of 269 (42%) patients died during that period. In Cox regression analysis, nitrate usage was associated with a slightly increased mortality risk compared with not using nitrates (hazard ratio 1.29; 95% confidence interval 1.01-1.65; P = .040), which continued modestly after the propensity-matched analysis (hazard ratio  1.26; 95% confidence interval 0.95-1.68; P = .102). In both prematch and propensity-matched analyses, nitrate use was not associated with risk of rehospitalization. No significant effect was detected on subgroups stratified by coronary artery disease, age, gender, and background medical therapy.Conclusions: In this study, oral nitrate use alone in addition to GDMT did not affect all-cause mortality and hospitalization risk in HFrEF patients during a long-term follow-up. There was even a modest tendency for increased risk of mortality. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: The aim was to evaluate the left ventricular wall motion abnormalities, perfusion and late contrast enhancement patterns on magnetic resonance imaging (MRI) in patients with 70% or higher degree stenosis or occlusion of coronary arteries on coronary angiography. Materials and Methods: Twenty-four patients (5 women, 19 men, age range 38-78, mean age 59.1) who had 70% or higher degree stenosis or occlusion of coronary arteries on coronary angiography who had been referred for cardiac MRI were included. On coronary angiography, 20 vessels were totally occluded [left anterior descending artery (LAD) 12; left circumflex coronary artery (LCx) 2; right coronary artery 6] and 20 vessels were severely stenotic (70-99%). In 5 patients' three vessels, in 6 patients' two vessels, and in 13 patients' a single vessel was involved. Wall motion, perfusion abnormalities, and late contrast enhancement consistent with nonviable myocardium were analyzed at apical, at midventricular, and basal levels on short-axis images of cardiac MRI in concordance with the segmental irrigation areas of the coronary arteries. Results: Impaired perfusion was observed on the corresponding irrigation segments of 39 vessels of 40 coronary artery branches. Wall motion abnormalities were present on corresponding irrigation areas of 30 severely stenotic vessels. Combined evaluation of wall motion and perfusion, segments with the decreased left ventricular contraction, and perfusion matched with the corresponding irrigation areas of all of the 40 stenotic or occluded vessels. Conclusion: A correlation was found between the combined assessments of myocardial perfusion, wall motion, and viability on late contrast enhancement on cardiac MRI with the clinical and angiography findings. Thus this combined MRI protocol can be used for the evaluation of ischemic heart disease. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: The purpose of our study was to compare gadopentate dimeglumine (Gd-DTPA) and gadobenate dimeglumine (Gd-BOPTA) for the evaluation of myocardial infarction (MI) and in the grading transmural extent on late-contrast enhanced cardiac magnetic resonance imaging. Materials and Methods: Twenty-three patients with clinically proven MI were examined with the use of 0.2 mmol/kg Gd-DTPA and 0.1 mmol/kg Gd-BOPTA in 2 days interval. All patients were examined with the use of segmented two-dimensional inversion-recovery turbo fast-field echo pulse sequence with an inversion time 210–300 milliseconds. Fifteen minutes time delay was used on both examinations after the injection of contrast agent. Contrast-to-noise ratio between normal myocardium and infarcted myocardium and signal intensity ratio (SIR) of the enhanced myocardium to blood pool was derived and compared for each contrast agent. Results: A total of 61 infarcted segments were analyzed. All of the infarcted segments were visualized on both Gd-BOPTA and Gd-DTPA enhanced images. There was statistically no significant difference between 0.2 mmol/kg Gd-DTPA and 0.1 mmol/kg Gd-BOPTA in the mean contrast-to-noise ratio (10.19 versus 10.22; P = .96), SNR (14.29 versus 14.25; P = .96), and SIR (4.34 versus 4.21; P = .38) of the infarcted segments. Intraobserver agreement (kappa) between Gd-DTPA and Gd-BOPTA were R1 = 91% and R2 = 86%. Interobserver agreements between the readers were Gd-DTPA = 85% and Gd-BOPTA = 88%. Conclusion: According to our data, the diagnostic efficacy of 0.1 mmol/kg dose Gd-BOPTA is equivalent to that of 0.2 mmol/kg Gd-DTPA for the assessment of MI on delayed enhanced magnetic resonance images. [Copyright &y& Elsevier]

This report emphasizes the importance of meticulous examination of the ventricular cavity on myocardial perfusion SPECT slices and the inclusion of hypertrophied papillary muscles in the differential diagnosis of cavitary radionuclide uptake. [ABSTRACT FROM AUTHOR]

Abstract: Congenital heart diseases may be seen isolated as well as in conjunction with other anomalies. Coarctation of aorta forms 6–8% of all congenital heart diseases. Most commonly, it is seen in conjunction with bicuspid aortic valve. Both disorders may be seen together with anomalies of coronary artery. We present here a case presenting with shortness of breath and diagnosed with coarctation of aorta, bicuspid aortic valve, and serious aortic stenosis together with a fistula between circumflex artery and descending aorta for which we recommended surgery. [Copyright &y& Elsevier]

Abstract: Background: Previous studies have shown improvement in left ventricular function and development of the reverse remodeling in the left ventricle and left atrium after cardiac resynchronization therapy (CRT). The aim of this study was to investigate the effect of CRT on left atrial appendage (LAA) function and pulmonary venous flow pattern. Methods: Eighteen patients with systolic heart failure and complete left bundle branch block underwent implantation of biventricular pacemaker devices. In order to follow changes in LAA, transthoracic and transesophageal echocardiographic examinations were performed 1 week before and repeated 1 and 6 months after pacemaker implantation. Results: CRT resulted in significant clinical improvement and decrease in NYHA functional class in 17 patients (94%). Maximum and minimum areas of left atrial appendage (LAAAmax and LAAAmin) decreased, with a concomitant increase in LAA ejection fraction. [LAAAmax: from 4.6±2 to 4.2±1.8 cm2 at the first (P<0.001) and to 4.0±1.8 cm2 at the sixth month (P<0.001); LAAAmin: from 2.7±1.3 to 2.3±1.2 cm2 at the first (P<0.001) and to 2.2±1.2 cm2 at the sixth month (P<0.001) and LAA ejection fraction: from 41±12% to 46±10% at the first (P=0.007) and to 47±8% at the sixth month (P=0.003)]. LAA active emptying and filling flow and pulmonary venous systolic velocities also increased after CRT. The appendage active emptying velocity correlated significantly with left ventricular ejection fraction (r=0.50, P=0.002), LAA ejection fraction (r=0.51, P=0.002), left atrial maximal volume, LAVmax (r=−0.44, P=0.007), left atrial minimal volume, LAVmin (r=−0.50, P=0.002) and pulmonary vein systolic flow velocity (r=0.33, P=0.05). Conclusion: Treatment of heart failure by CRT results with marked improvements in LAA function and increases pulmonary venous systolic velocity. [Copyright &y& Elsevier]

Abstract: Objective: Underlying predisposition for a heightened inflammatory response is postulated as one of the mechanisms for elevated high-sensitivity C reactive protein (hs-CRP) levels in patients with acute coronary syndrome (ACS). It is unclear whether metabolic syndrome (MetS) may cause a predisposition for heightened hs-CRP response in patients with ACS. The aim of this study is to investigate the interaction between hs-CRP levels and presence of MetS in patients with and without ACS. Methods: Two hundred and seventy-three consecutive patients presenting with a first ACS event and 261 MetS patients without any ACS event were included to the study. The study participants were divided into three groups as MetS (+) ACS (−) [n =261], MetS (−) ACS (+) [n =110], and MetS (+) ACS (+) [n =163]. Median levels of hs-CRP were compared between and within the three groups. Results: Hs-CRP levels were lowest in MetS (+) ACS (−) subjects and highest in MetS (+) ACS (+) patients. Factors associated with hs-CRP levels were troponin elevation, presence of ACS, body mass index (BMI), and presence of MetS (R 2 =0.26, p <0.01). Predictors of elevated hs-CRP levels (>0.3mg/dl) were the presence of ACS (OR=3.6, 95% CI=1.9–6.5, p <0.01), presence of MetS (OR=2.1, 95% CI=1.0–4.0, p =0.02), troponin elevation (OR=5.7, 95% CI=2.8–11.5, p <0.01) and BMI (OR=1.1, 95% CI=1.0–1.1, p <0.01). Conclusions: The presence of MetS had an impact on the increase in hs-CRP levels observed with an ACS event in the study population. These findings suggested that a heightened baseline inflammatory status of MetS may predispose ACS patients to an augmented hs-CRP response. [Copyright &y& Elsevier]

Abstract: Objective: Emerging evidence indicates the prognostic importance of Cystatin C (Cys-C) in patients with coronary artery disease. However, whether Cys-C concentrations are associated with adverse clinical events among patients with acute coronary syndromes (ACS) have not been studied extensively. We compared the long-term prognostic efficacy of Cys-C with other markers of renal dysfunction, inflammation and systolic dysfunction in patients with ACS. Methods and results: Serum levels of Cys-C, high sensitive C-reactive protein (hs-CRP), brain natriuretic peptide (BNP) and creatinine were measured in 160 patients with ACS (112 males, 48 females, mean age 60±10 years) on admission. Primary end point of the study was major adverse cardiac events (MACE) defined as the combination of cardiac death, non-fatal myocardial infarction and recurrent rest angina that required hospitalization within 12 months of follow-up. During the follow-up period, 42 (26%) patients met the MACE criteria. The occurrence of MACE was significantly higher among patients with higher Cys-C levels. In multivariate analysis, Cys-C was the most important parameter associated with the occurrence of MACE (OR=9.62, 95% CI=2.3–40.5, p <0.001). ROC curve analysis showed that the predictive cut-off value of Cys-C for MACE was 1051ng/ml. In the Cox regression analysis adjusted for multiple risk factors, Cys-C was found as the most powerful predictor for MACE (RR=9.43, 95% CI=4.0–21.8, p <0.001). Conclusion: The results of the present study indicate that admission levels of Cys-C may be a good prognostic indicator of recurrent cardiovascular events in patients with ACS. Further studies are needed to confirm these results. [Copyright &y& Elsevier]

Abstract: Background: Although different populations were examined for the incidence of aspirin resistance, the frequency and related risk factors for aspirin resistance in patients with metabolic syndrome have not been reported yet. This study aimed to determine the frequency of aspirin resistance and its risk factors in patients with metabolic syndrome. Methods: We performed a cross-sectional study in 110 patients with metabolic syndrome. After one week of 100 mg/day aspirin, blood samples were obtained. Platelet function analyzer (PFA-100™) was used to determine the frequency of aspirin resistance. Endothelial functions, carotid intima media thickness, and the presence of plaques in the carotid arteries were evaluated for subclinical atherosclerosis and the levels of inflammatory markers were assessed as risk factors for aspirin resistance. The presence of subclinical atherosclerosis was defined as a maximum carotid intima media thickness of ≥0.9 mm and/or the presence of carotid atheroma. Results: Aspirin resistance was detected in 21.9% of the patients. In the multivariate analysis, hs-CRP levels (odds ratio [95% CI]=2.8 [1.3–5.9], p =0.009), diastolic blood pressure, (0.9 [0.8–1.0], p =0.007), and the presence of subclinical atherosclerosis (4.1 [1.4–12.2], p =0.012) were statistically significant risk factors for aspirin resistance. Conclusions: We concluded that the frequency of aspirin resistance confirmed in this cohort of patients with metabolic syndrome was higher in patients with a lower diastolic blood pressure, higher hs-CRP levels and atherosclerotic changes in their carotid arteries. [Copyright &y& Elsevier]

Abstract: Background: Patients with dilated cardiomyopathy (DCM) have an increased risk of thromboembolic events. Incidence of silent cerebral infarction (SCI) has not been investigated in these patients. The aim of this study was to investigate the incidence of SCI in patients with DCM and to determine its associations with echocardiographic parameters. Methods and results: Seventy-two patients (mean age 62±12 years) with DCM underwent cranial magnetic resonance imaging in addition to transthoracic and transesophageal echocardiographic examination. A total of 56 age-matched healthy volunteers served as a control group for comparison SCI prevalence. Prevalence of SCI was significantly higher in patients with DCM (35% vs. 3.6%; p <0.001). In DCM group, patients with SCI had significantly impaired left ventricular systolic function, higher frequency of restrictive diastolic filling, moderate to severe left atrial spontaneous echo contrast (SEC), aortic SEC, and complex atherosclerosis or calcified plaques in the aorta. In logistic regression analysis, type of diastolic filling emerged as the only independent risk factor for SCI (p <0.001). When the type of diastolic filling was removed from the analysis, ejection fraction, marked left atrial SEC, complex-calcified aortic atheroma and age appeared as the other independent risk factors (p =0.003, p =0.009, p =0.013 and p =0.018, respectively). Conclusion: SCI is a frequent finding in DCM patients. Impaired systolic function, restrictive filling pattern, presence of moderate to severe left atrial SEC, and complex atherosclerosis in the aorta are the factors contributing to the development of SCI. [Copyright &y& Elsevier]

Abstract: Cor triatriatum dextrum is a rare congenital malformation, usually associated with complex right heart abnormalities, characterized by a membrane that divides the right atrium into two chambers. It is considered the result of the incomplete and abnormal regression of the embryonic right valve of the sinus venosus. With an incomplete regression, a fenestrated or an unfenestrated membrane may persist in the right atrium. Cor triatriatum dextrum may be seen with congenital cardiac defects associated with the right heart. We have diagnosed infective endocarditis in a 19 year old male patient with asymptomatic incomplete cor triatriatum dextrum, PFO and valvular–infundibular severe pulmonary stenosis based on the Duck criteria, with a positive blood culture and 3 minor criteria. Echocardiography did not reveal any vegetations. Antibiotherapy was given and then regions responsible of the stenosis were resected surgically. After surgery a small outlet type VSD development was observed. [Copyright &y& Elsevier]