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Aortic valve stenosis (AS) is common in the elderly. Nowadays surgical aortic valve replacement still has been the gold standard of management, but many patients have been excluded from surgery given that they were very old, frail, or had co-morbidities that increased operative risks. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a new treatment option for these patients. Despite being less invasive than surgery, TAVI has rare but fatal complications like vascular injuries. Vascular injuries are the most common complications after TAVI, and range from dissection, to perforation, to acute thrombotic occlusion. We report a case of left main coronary artery (LMCA) occlusion following TAVI that caused cardiac arrest and was managed successfully with emergency percutaneous coronary intervention (PCI).

Background Septal reduction therapy can be considered along the lines of hypertrophic obstructive cardiomyopathy patients who have drug-refractory symptoms. This can be applied either surgical myectomy or either alcohol septal ablation (ASA). Alcohol septal ablation has been performed successfully since the first announcement of ASA in 1995. Case summary We present a case report of coronary artery vasospasm that occurred in the left anterior descending artery (LAD) during ASA. We performed ASA via first septal artery. Two cubic centimetre of 99% ethanol was slowly injected and 10 min later balloon was withdrawn. Then the patient felt severe chest pain; his systolic blood pressure went down quickly and fibrillated. We started the cardiopulmonary resuscitation (CPR). After CPR, the rhythm was achieved total 4 min later cardiac arrest but blood pressure was low. Emergent coronary angiography showed that coronary spasm caused severe occlusion in the LAD segment just after the first septal artery and impaired coronary flow nearly totally in the LAD just after septal artery. At that time, we decided to implant a stent due to the patient’s serious condition and a 3.5 × 18 mm drug-eluting stent was implanted. We performed control angiography to patient 3 days later of the procedure and LAD flow was TIMI 3. Discussion The causes of LAD occlusion are alcohol leakage, dissection, and vasospasm. It is important to detect the correct reason for appropriate treatment. Alcohol leakage impairs and causes coronary flow disruption; this can cause ventricular wall motion abnormalities. In our case, there was severe spasm in the LAD coronary artery and LAD flow was severely impaired. On echocardiogram, there was no myocardial wall motion abnormality. So alcohol leakage was ruled out. Left anterior descending artery image was not typical dissection. As a result of these findings, we concluded that the cause of LAD occlusion was coronary artery vasospasm.

Article history: Received 20 November 2015 Accepted 22 November 2015 Available online 23 November 2015 artery dissection and rupture after successful TAVI procedure with axillary artery approach. The patient was admitted to our hospital because of severe and symptomatic aortic valve stenosis. The patient had hypertension, dyspnea and syncope on her history. On physical examination, the arterial blood pressure was 138/65 mmHg, the pulse was 86 bpm. There was a 4/6 systolic murmur on the right sternal border radiating to the right side of the neck. The peripheral arterial

Article history: Received 11 October 2015 Accepted 18 October 2015 Available online 19 October 2015 Firstly, we decided to try the percutaneous transapical approach with a needle without left minithoracotomy. Under general anesthesia, we performed coronary angiography in order to not puncture the left anterior descending artery in apical region (Fig. 2). After that, under TEE and fluoroscopic angiographic guidance, transapical cannulation of the left ventricle from the sixth intercostal area and midclavicular region with a needle was performed and a 6 F sheath was inserted to

The transapical transcatheter approach for percutaneous interventions is performed in high-risk patients with peripheral vascular disease and when transseptal attempt failed. The apical access is traditionally performed through a left minithoracotomy at the fifth intercostal space under general anesthesia. But, there are some complications and risks like ventricular arrhythmias, ventricular tear and life-threatening surgical bleeding in the apical access even though it is a minimally invasive procedure [1]. Although new apical closure devices have been developed and tested in animals and humans, the apical closure remains a challenge in recent studies [2]. The cardiologists started to use the occluders to closure the percutaneous apical accesses [3–11]. We report a case of a successful percutaneous closure of the apical access with a 4 mm ADO-II device after a standard transapical mitral paravalvular leak closure procedure without minithoracotomy. A67year old femalewas admitted to our departmentwith severe dyspnea (NHYA classes II–III). And she had hemolytic anemia (hemoglobin level 9.0 g/dL, lactate dehydrogenase 1588 IU/L). She had a history of mitral bioprosthesis valve replacement in 1997 and metallic mitral valve replacement in 2005. Transesophageal echocardiography (TEE)

Inflammation plays an important role in the pathophysiology of vascular disease. In this review, we consider the associations between the neutrophil–lymphocyte ratio (NLR; an indicator of inflammation) and vascular disease and its associated risk factors. The NLR has received attention due to its role as an independent prognostic factor for coronary artery disease. The NLR can also be affected by atherosclerotic risk factors, such as hypercholesterolemia, metabolic syndrome, diabetes, and hypertension. Importantly, it can predict mortality in cardiovascular diseases. There are also reports of a positive correlation between the NLR and commonly used inflammatory markers. Inflammation is important not only in pathophysiology but also clinical outcomes of many diseases. The NLR is a widely available, easily derived, and reproducible marker of inflammation. Unlike many other inflammatory markers, the NLR is inexpensive and readily available and it provides additional risk stratification beyond conventional risk scores.

Vascular inflammation plays an important role in the pathophysiology of hypertension and high levels of endocan may reflect ongoing vascular inflammation in hypertensive patients. In the present hypothesis-generating study, we aimed at investigating the comparative effects of amlodipine and valsartan on endocan levels in newly diagnosed hypertensive patients. The study population consisted of 37 untreated hypertensive patients who were randomized to the two treatment arms. After baseline assessment, each patient was randomly allocated to either 10 mg daily of amlodipine (n = 18, 7 males) or 160 mg daily of valsartan (n = 19, 3 males) and treated for a 3-month period. Sphygmomanometric blood pressure (BP) and serum endocan were measured before and every 2 weeks during drug treatment. There was no statistically significant difference between the two treatment arms as far as baseline socio-demographic and clinical characteristics are concerned. After a 3-month treatment period, systolic and diastolic BP values significantly reduced by antihypertensive treatment (p < 0.001). Furthermore, endocan levels were significantly decreased in both treatment arms (p < 0.05). However, amlodipine caused a greater percent decrease in circulating endocan levels compared with valsartan at the end of the treatment period. Both drugs reduced high sensitivity C-reactive protein values. However, the statistical significant difference vs baseline was achieved only in the group treated with amlodipine. No correlation was found between endocan plasma levels and BP reduction. The results of this hypothesis-generating study suggest that amlodipine and valsartan decrease endocan levels in newly diagnosed hypertensive patients. The effects, which are more evident with amlodipine, may contribute to the anti-inflammatory effects exerted by the two drugs on the vascular target.

Behçet disease (BD) is associated with endothelial dysfunction and chronic inflammation. The neutrophil–lymphocyte (N/L) ratio and carotid intima–media thickness (cIMT) are markers of inflammation and vascular risk, respectively. We assessed the relationship between cIMT values and N/L ratio in BD (65 patients and 62 control participants). There were statistically significant differences in N/L ratios and cIMT values between the patients with BD and control group ( P < .001). There were moderate positive correlations between cIMT value, C-reactive protein, and N/L ratio in patients with BD. Receiver–operating characteristic curve analysis suggested that the optimum N/L ratio cutoff point for patients with BD was 1.29, with a sensitivity, specificity, negative predictive value, and positive predictive value of 97, 77, 96, and 75%, respectively (area under curve: 0.691, 95% confidence interval = 0.600-0.782, P < .001). The N/L ratio may be a useful index of BD activity.

Article history: Received 3 November 2015 Accepted 4 November 2015 Available online 5 November 2015 (ACS) [1]. Ticagrelor has more rapid onset of action on platelet inhibition and was superior to clopidogrel. It decreases major adverse cardiac events compared to the clopidogrel. According to the PLATO trial, ticagrelor may lead to increased incidence of asymptomatic ventricular pauses [1–4]. In addition, there are some reports about the side effects of ticagrelor like bradycardia and dyspnea [5–8]. It is considered that the inhibition of the re-uptake of adenosin from the red cells

Takotsubo cardiomyopathy(TCM) is a reversible cardiomyopathy characterized by left ventricular dysfunction due to transient left ventricular apical hypokinesia or akinesia and basal hyperkinesis following some trigger factors like physical or emotional stressful events and may mimic myocardial infarction especially in middle age females. Pathophysiology of TCM is not clear but it is associated with excessive adrenergic stimulation[1-3]. TCM is usually precipitated by acute physical and emotional stresssors, use of exogenous catecholamines or exacerbation of chronic illnesses like asthma attack. We report a case of TCM after an asthma attack as a potential stressor. This is an interesting association between asthma attack and TCM.

☆ There is no conflict of interest. ☆☆ This statement is to certify that all authors have see being submitted, have contributed significantly to thewor imacy of the data and its interpretation, and agree to its Journal of Cardiology. ★ We attest that the article is the Authors' original w lication and is not under consideration for publication else ment of ethical publishing as appears in the International ★★ On behalf of all Co-Authors, the corresponding Aut for the submission. Any changes to the list of authors, inclu or removals will require the submission of a new author signed by all the original and added submitting authors. ☆☆☆ All authors are requested to disclose any actual or cluding any financial, personal or other relationships with within three years of beginning the submitted work that c or be perceived to influence, their work. If there are no con read: “The authors report no relationships that could be co ⁎ Corresponding author at: Department of Cardiolog Tevfik Saglam St., 06018 Etlik, Ankara, Turkey. Tel.: +9 3044250. E-mail address: drcengizozturk@yahoo.com.tr (C. O

The transapical transcatheter approach for percutaneous interventions is performed in high-risk patients with peripheral vascular disease and when transseptal attempt failed. The apical access is traditionally performed through a left minithoracotomy at the fifth intercostal space under general anesthesia. But, there are some complications and risks like ventricular arrhythmias, ventricular tear and life-threatening surgical bleeding in the apical access even though it is a minimally invasive procedure [1]. Although new apical closure devices have been developed and tested in animals and humans, the apical closure remains a challenge in recent studies [2]. The cardiologists started to use the occluders to close the percutaneous apical accesses [3–11]. We report a case of a successful percutaneous closure of the apical access with a 4 mm ADO-II device after a standard transapical mitral paravalvular leak closure procedure without minithoracotomy with the computed tomography guidance. This case is the second from Turkey, so the first one was published recently in this journal [12]. In this second case, we used the CT guidance for optimal puncture of cardiac apex. A 44 year old female was admitted to our department with severe dyspnea (NHYA classes II–III). She had hemolytic anemia (hemoglobin level 8.0 g/dL, lactate dehydrogenase level was high). She had a history ofmitralmetallic prosthesis valve replacement in 1994. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and 9mm) of themitral valve prosthesis. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and

Endothelial dysfunction is regarded as the initial lesion in the development of atherosclerosis. Endocan, previously called endothelial cell–specific molecule 1 (ESM-1), is a new candidate immunoinflammatory marker that may be associated with cardiometabolic risk factors. Therefore, we assessed serum levels of endocan in newly diagnosed patients with untreated essential hypertension (HT). A total of 18 patients with HT and 23 normotensive control participants were included in the study. Serum endocan levels, carotid intima–media thickness (cIMT), and high-sensitivity C-reactive protein (hsCRP) were measured. Serum endocan levels were significantly higher in the HT group ( P < .001). In patients with HT, serum endocan levels correlated positively with cIMT and hsCRP ( r = .551, P < .001 and r = .644, P < .001, respectively). Our findings suggest that circulating endocan levels represent a new marker in patients with essential HT. Endocan may be a surrogate endothelial dysfunction marker and may have a functional role in endothelium-dependent pathological disorders.

Mitral valve prolapse (MVP) is the most common valvular heart disease and characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are two types of MVP, broadly classified as classic (thickness ≥5 mm) and non-classic (thickness5 mm) according to the morphology of the leaflets. We aimed to investigate elastic properties of the aorta in young male patients with classical and non-classical MVP.In the present study, 63 young adult males (mean age: 22.7 ± 4.2) were included. Patients were divided into classic MVP (n = 27) and non-classic MVP (n = 36) groups. Aortic strain, aortic distensibility and aortic stiffness index were calculated by using aortic diameters obtained by echocardiography and blood pressures measured by sphygmomanometer.There was no significant difference between the groups in terms of age, body mass index, left ventricular mass and ejection fraction. When comparing the MVP group it was found that aortic strain and aortic distensibility were increased (p = 0.0027, p = 0.016, respectively) whereas the aortic stiffness index was decreased (p = 0.06) in the classical MVP group.We concluded that the elastic properties of the aorta is increased in patients with classic MVP. Further large scale studies should be performed to understand of morphological and physiological properties of the aorta in patients with MVP.

Background: Cardiac syndrome X (CSX) is characterised by angina-like chest pain, a positive stress test, and normal coronaryarteries. Increased red cell distribution width (RDW) level may be indicative of an underlying inflammatory state. Aim: To investigate RDW level in patients with CSX and compare patients having coronary artery disease (CAD) and normalsubjects. Methods: 245 subjects (79 patients with CSX, 81 patients with CAD, and 85 controls) were enrolled in the study. The CSXgroup consisted of patients with anginal chest pain, ischaemia on noninvasive stress test and a normal coronary angiogram.CAD was defined as ≥ 50% stenosis in at least one coronary artery. The control group was selected from the patients withanginal symptoms but a normal stress test and a normal coronary angiogram. RDW measurements among the three groupswere compared. Results: Baseline clinical and biochemical characteristics were not different among the three groups. There were no statisticallysignificant differences in RDW levels between the CSX and CAD groups (p = 0.17). RDW measurements in both theCSX and CAD groups were found to be significantly higher than the control group (p < 0.01). Conclusions: We discovered that patients with CSX and CAD have significantly higher RDW measurements compared tocontrols. The relationship between CSX and higher RDW level suggests that endothelial dysfunction may also contribute tothe etiopathogenesis of the CSX phenomenon as it does with CAD.

Psoriasis is associated with an increased risk of atherosclerosis. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness. We aimed to investigate the relationship between arterial stiffness and high-sensitivity C-reactive protein (hsCRP) in patients with psoriasis. A total of 32 patients with psoriasis and 35 patients with other skin diseases were included in the study. The hsCRP levels and arterial stiffness measurements were compared. Arterial stiffness was significantly different between the 2 groups ( P = .01). Arterial stiffness was not associated with the duration of the disease or the disease activity ( P = .34 and .64, respectively). In patients with psoriasis, arterial stiffness correlated positively with age, sex, body mass index, diastolic blood pressure, and hsCRP level ( P < .05). These findings provide further evidence of a link between inflammation, premature atherosclerosis, and psoriasis.

Background: The slow coronary flow (SCF) is characterized by angiographically normal or near-normal coronary arteries with delayed progression of the contrast agent into distal vasculature. We aimed to investigate neutrophil-to-lymphocyte (N/L) ratio and the carotid intima-media thickness (CIMT) value in patients with SCF compared to patients with newly diagnosed coronary artery disease (CAD) and normal patients. Materials and Methods: We enrolled 60 consecutive patients with SCF, 68 patients with CAD, and 72 normal patients. The association between thrombolysis in myocardial infarction frame count, CIMT, and N/L ratio and other clinical and laboratory parameters were evaluated. Results: The N/L ratio was significantly higher not only in patients with SCF but also in patients with CAD, compared to those of controls. The N/L ratio was positively and moderately correlated with CIMT in the whole study population. Conclusions: The NL ratio is significantly associated with reduced coronary blood flow, and elevated N/L ratio might be an independent predictor for the presence of SCF.

Atherosclerosis plays an important role in the etiopathogenesis of coronary artery ectasia (CAE). Inflammation markers may play a part in the pathogenesis of CAE. We aimed to assess the association between the CAE and the neutrophil–lymphocyte (N/L) ratio. Consecutive eligible patients (n = 181) were divided into 3 groups: patients with CAE, those with newly diagnosed coronary artery disease (CAD), and those with a normal coronary angiogram. The N/L ratio and mean platelet volume (MPV) were measured as part of the automated complete blood count. There were no statistically significant differences in N/L ratio and MPV between the CAE and the CAD groups. The N/L ratio and MPV were significantly higher in patients in both CAE and CAD groups compared to those in the control group ( P < .01). An increased N/L ratio may play a role not only in the pathogenesis of CAD but also in the pathophysiology of CAE.

Background: To date, several validated patient-based risk scores have been established to predict mortality and morbidity in patients presenting with ST-segment elevation myocardial infarction (STEMI). The Gensini score was originally developed to quantify the severity of coronary artery disease (CAD). Objectives: We intend to assess the association between severity of CAD assessed by Gensini score and in-hospital mortality in patients with STEMI undergoing primary percutaneous coronary intervention (P-PCI). Methods: A total of 539 patients presenting with acute STEMI, who underwent P-PCI within the first 12 hours from the onset of symptoms, were included. The severity of CAD was expressed as the sum of the Gensini scores for each lesion. Patients' demographic variables, medical histories and clinical features, as well as in hospital major adverse events were obtained from the medical reports. Results: Of these 539 patients, 416 (77.2%) were male and mean age was 59.14 ± 12.68 years. In-hospital mortality rate was 5.4% (29 patients; 16 men). Mortality rate was 10.5% in female patients and 3.8% in males (P = 0.004). Mean Gensini scores were significantly different in the comparison between patients who survived (54.54 ± 26.34) and those who died (80.17 ± 26.51) (P = 0.001). The multivariable Cox proportional hazards regression analysis model revealed that the Gensini score (P = 0.037), female gender (P = 0.039), serum urea levels (P = 0.041), uric acid levels (P = 0.008) and LVEF (P = 0.001) were independently associated with in-hospital mortality in patients with STEMI undergoing P-PCI. Conclusion: The Gensini score is independently associated with in-hospital mortality in STEMI patients treated with P-PCI. Therefore, it might play an important role in risk stratification of STEMI patients. Resumo Fundamento: Até o momento, diversos escores de risco baseados em pacientes foram estabelecidos para a predição de mortalidade em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). O escore de Gensini foi originalmente desenvolvido para quantificar a gravidade de doença arterial coronariana (DAC). Objetivos: Avaliar a associação entre a gravidade de DAC avaliada pelo escore de Gensini e mortalidade intra-hospitalar em pacientes com IAMCSST submetidos à intervenção coronária percutânea primária (ICP-P). Métodos: Foram incluídos 539 pacientes com IAMCSST, submetidos à ICP-P dentro das primeiras 12 horas do início dos sintomas. A gravidade da DAC foi expressa como a soma do escore de Gensini para cada lesão. Variáveis demográficas, anamnese e características clínicas dos pacientes, bem como eventos hospitalares significativos, foram obtidos de relatórios médicos. Resultados: Dos 539 pacientes, 416 (77,2%) eram do sexo masculino, e a idade média era 59,14 ± 12,68 anos. A taxa de mortalidade intra-hospitalar foi de 5,4% (29 pacientes, 16 homens). A taxa de mortalidade foi de 10,5% em pacientes do sexo feminino e 3,8% em pacientes do sexo masculino (P = 0,004). Os escores de Gensini médios mostraram-se significativamente diferentes na comparação entre pacientes que sobreviveram (54,54 ± 26,34) e aqueles que foram a óbito (80,17 ± 26,51) (P = 0,001). O modelo de análise multivariada de regressão de Cox de risco proporcional revelou que o escore de Gensini (P = 0,037), o sexo feminino (P = 0,039), níveis séricos de ureia (P = 0,041), níveis de ácido úrico (P = 0,008) e FEVE (P = 0,001) estavam independentemente associados à mortalidade intra-hospitalar em pacientes com IAMCSST submetidos à ICP-P. Conclusões: O escore de Gensini está independentemente associado à mortalidade intra-hospitalar em pacientes com IAMCSST tratados com ICP-P. Portanto, o escore pode ter um papel importante na estratificação de risco de pacientes com IAMCSST.

Severe aortic stenosis is associated with significant morbidity and mortality if untreated. The transcatheter aortic valve implantation(TAVI) is now feasable and effective gold standart treatment option in patients with severe aortic valve stenosis(AS) and associated with similar rate of major adverse events compared to the surgery. The relation between aortic stenosis and gastrointestinal angiodysplasia was known as Heyde’s Syndrome since 1958. High fluid shear stress through the narrowed valve is thought to be the underlying mechanism leads to the mechanical disruption of the large von Willebrand factor multimers. Aortic valve replacement either surgical or with TAVI seems to reduce gastrointestinal bleeding in approximately 80% in patients with Heyde syndrome in whom gastrointestinal bleeding is associated with intestinal angiodysplasia due to acquired von Willebrand’s disease (type 2A) and aortic valve stenosis. The patients especially with atrial fibrillation who need anticoagulant therapy may have bleeding risk despite aortic valve replacement. We report a case of patient presenting with a massive intestinal bleeding originating from intestinal angiodysplasia after percutaneous aortic valve replacement.

The endovascular aortic repair (EVAR) is the treatment of choice for the majority of patients with abdominal aortic aneurysms(AAA) by supporting endovascular technology. But there are some potential complications during or post procedure. We present a case who underwent endovascular aortic repair (EVAR) for an AAA occured splenic artery infarction after procedure.

The no-reflow (NR) phenomenon represents an acute reduction in coronary blood flow without coronary vessel obstruction, coronary vessel dissection, spasm, or thrombosis. No reflow is an important complication among patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The complete blood count (CBC) is one of the most frequently ordered laboratory tests in clinical practice. Various studies have evaluated the performance of CBC parameters to predict disease severity and mortality risk. Automated cell counters are routinely available in many clinical laboratories and can be used to determine red blood cell distrubiton width (RDW), platetecrit, platelet count, and and some ratios like the neutrophil–lymphocyte ratio and RDW-platelet ratio. These hematological markers have been reported to be independent predictors of impaired angiographic reperfusion and long-term mortality among patients with STEMI undergoing pPCI. In this context, we reviewed the role of admission CBC parameters for the prediction of NR in patients with STEMI undergoing pPCI.

Here, we report a case of late device embolization to the abdominal aorta at the level of the superior mesenteric artery, approximately one month after percutaneous closure of an ASD.

We discuss the relationship between several factors and the risk of vascular events in patients with Behçet's disease.Behçet's disease, a systemic, chronic relapsing vasculitis, is mainly seen in the Mediterranean area and is typically characterized by recurrent oro-genital ulcers, ocular inflammation, and skin manifestations, including articular, vascular, gastroenteric, and neurological involvement. It is a chronic inflammatory disease with relapses and remissions. The prognosis varies. Behçet's disease can cause venous or arterial lesions. Vascular involvement contributes to the mortality and morbidity associated with Behçet's disease.The cause of thrombosis or vascular events in Behçet's disease remains incompletely understood; several factors have been studied with conflicting results. Vasculitis is considered to underlie several clinical manifestations of Behçet's disease.

No-reflow phenomenon is a prognostic value in ST-segment elevation myocardial infarction (STEMI). Monocyte to high density lipoprotein ratio (MHR) has recently emerged as a marker of inflammation and oxidative stress in the cardiovascular disease.In this study, we aimed to investigate the relation between MHR and no-reflow phenomenon in patients with STEMI undergoing primary percutaneous coronary intervention (pPCI).A total of 600 patients with STEMI (470 men; mean age, 62 ± 12 years) admitted within 12 hours from symptom onset were included into this study. Patients were classified into 2 groups based on postintervention Thrombolysis in Myocardial Infarction (TIMI) flow grade: no-reflow-TIMI flow grade 0, 1, or 2 (group 1); angiographic success-TIMI flow grade 3 (group 2).According to admission whole-blood cell count results, the patients in the no-reflow group had significantly higher monocyte count and MHR values when compared with those of the reflow patients. After multivariate backward logistic regression, MHR remained independent predictors of no reflow after pPCI. Adjusted odds ratios were calculated as 1.09 for MHR (P.001; confidence interval [CI], 1.07-1.12). Receiver operating characteristic curve analysis suggested that the optimum MHR level cutoff point for patients with no-reflow was 22.5, with a sensitivity and specificity of 70.2% and 73.3%, respectively (area under curve, 0.768; 95% CI, 0.725-0.811).In conclusion, MHR levels are one of the independent predictors of no reflow in patients with STEMI after pPCI.