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Aims: This study aimed to assess the use of transthoracic and transoesophageal echocardiography in diagnosing the thrombi located in the left atrium and/or left atrial appendage in patients with rheumatic mitral valve disease, and to investigate the characteristics of thrombi in comparison to intraoperative findings.Methods and Results: The study group was comprised of 474 patients who underwent transthoracic and transoesophageal echocardiography prior to mitral valve surgery. Location, thickness and morphological characteristics of thrombi were determined by transoesophageal echocardiography. Intraoperative assessment disclosed left atrial thrombi in 105 patients. Thickness of thrombi ≤1 cm, and thrombi confined to left atrial appendage were associated with false-negative results by transthoracic echocardiography. However, diameter and morphological characteristics of thrombi, left atrial and left atrial appendage size, and the presence of the spontaneous echo contrast were not associated with the diagnosis of thrombi by transthoracic echocardiography. For overall left atrial thrombi, sensitivity and specificity of transthoracic echocardiography were 32%, and 94%, respectively. Sensitivity and specificity of transoesophageal echocardiography for thrombi in the left atrial appendage were 98%, and 98%, for thrombi in the main left atrial cavity were 81%, and 99%, and for thrombi located in both left atrium and appendage cavities were 100%, and 100%, respectively.Conclusion: In patients with rheumatic mitral valve disease, detection of left atrial thrombi by transthoracic echocardiography seems to be determined by thickness and location of thrombi. The multilobed structure of the left atrial appendage and artifacts over posterior wall of the left atrium may still prevent precise diagnosis even with transoesophageal echocardiography. [ABSTRACT FROM AUTHOR]

This report presents three patients with severe pulmonary hypertension secondary to atrial septal defect associated with thrombus and spontaneous echo contrast within the pulmonary artery diagnosed by transthoracic and transoesophageal echocardiography. Clinical and echocardiographic features seem to suggest local thrombus formation within the pulmonary arteries as a direct consequence of pulmonary hypertension rather than venous thromboembolism. [ABSTRACT FROM AUTHOR]

The article describes the case of a 59-year-old woman with a suspected infective endocarditis. The patient reported to have a history of controlled hypertension and was referred to the hospital for a possible cardioembolic stroke. Her electrocardiogram revealed a sinus rhythm and a heart rate of 70 beats per minute. Also mentioned are the symptoms of infective endocarditis experienced by the woman.

Background: To investigate the relationship between anxiety and white coat hypertension (WCH) using the hospital anxiety and depression scale-anxiety (HADS-A) score., Methods: Participants lacking a pre-existing diagnosis of hypertension but displaying increased office blood pressure were included in this study. Subsequently, they were classified as either newly diagnosed sustained hypertension (SustHT) or white coat hypertension (WCH) patients, as determined by 24-hour ambulatory blood pressure monitoring measurements. The assessment of their anxiety levels was conducted using the HADS-A questionnaire. We performed regression, comparative, and sensitivity analyses to elucidate the association between anxiety and WCH., Results: In this cohort of 303 consecutive individuals (mean age 54 years, 46% female), 81 (26.7%) patients were diagnosed with WCH. Those with WCH were younger (49 vs. 56 years, P < .001), had higher heart rate (85 vs. 76 bpm, P < .001) and exhibited a female predominance (56% vs. 43%, P = .049) compared to individuals with SustHT. The HADS-A was higher in WCH than in SustHT (9.0 ± 2.9 vs. 6.6 ± 2.6, P < .001). Furthermore, HADS-A showed positive correlation with systolic and diastolic pressures measured in the out-patient clinic (r = 0.523 and r = 0.387, respectively; P < .001 for both). The full model with HADS-A had better discriminatory power (Harrell's c-index 0.82 vs. 0.77, P = .0025), increased calibration, and a greater net benefit than the base model without. The ROC curve analysis, using a cut-off of >6 for HADS-A, demonstrated a sensitivity of 76.5% and specificity of 53.6% in detecting WCH (Area Under the Curve = 0.72, P < .001)., Conclusions: Our study revealed that individuals with WCH, in comparison to those with SustHT, exhibit a higher level of anxiety as indicated by HADS-A.

Background: In patients with symptomatic mitral PVL, successful transcatheter reduction of the PVL to less than mild is associated with significant improvement in short- and midterm survival., Objectives: In this study, we present our single-centre, same operators' experience on percutaneous paravalvular leak closure with techniques and outcomes., Methods: In this retrospective observational designed study, we retrieved hospital records of patients with a surgical history of mechanical or biological prosthetic valve replacement and who subsequently underwent transcatheter mitral paravalvular leak closure (TMPLC). All procedures were performed by the same operators., Results: A total of 45 patients with 58 PVDs underwent TMPLC using 60 devices. All patients had moderate or severe mitral paravalvular regurgitation associated with symptomatic HF (15.6%), clinically significant haemolytic anaemia (57.8%) or both (26.7%). The technical success rate was 91.4%, with 53 defects successfully occluded. The clinical success rate was 75.6%. Among the clinical success parameters, the preprocedural median ejection fraction increased from 45% (35-55) to 50% (40-55) ( p  = .04). Mitral gradients decreased from max/mean 18/8 mmHg to max/mean 16/7 mmHg; p  = .02). Haemoglobin levels increased from 9.9 (8.5-11.1) to 11.1 (3-13); p  = .003. LDH levels decreased from 875 (556-1125) to 435 (314-579); p : <.001. All-cause 30-day and in-hospital mortality rates were the same at 8.9%., Conclusion: This single-centre study with a limited number of patients confirmed that TMPLC is a safe and effective procedure to improve symptoms and severity of PVL.

Background: The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs., Methods and Results: A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P =0.549) and procedural success (73.7 versus 65.2%; P =0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P =0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P <0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P =0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P =0.679)., Conclusions: The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Background: In this study, we investigated whether left atrial functions evaluated by speckle tracking echocardiography , classic echocardiographic and clinic parameters predict appropriate Implantable Cardioverter Defibrillator (ICD) shock in patients who underwent ICD implantation for hypertrophic cardiomyopathy., Methods: Totally 87 patients who received ICD implantation for primary or secondary prevention were included in the study. Patients' clinical, electrocardiographic, 2 dimen- sion classic, and speckle tracking echocardiographic data were collected. Left atrial functions were assessed by speckle tracking echocardiography. Left atrial strain just before mitral valve opening was taken as peak atrial longitudinal strain. Appropriate ICD therapy was defined as cardioversion or defibrillation due to ventricular tachycardia or fibrillation. Patients were divided into 2 groups as occurrence or absence of appropri- ate ICD therapy during follow-up (mean, 50.2 ± 9.3 months). Patients with an European Society of Cardiology (ESC) risk score >6% were considered high-risk patients., Results: A total of 24 (27.5 %) patients were observed to have an appropriate ICD therapy. In patients on whom appropriate ICD therapy was performed, a higher Sudden Cardiac Death risk Score and decreased peak atrial longitudinal strain and global longitudinal peak strain were observed. In patients with high ESC risk score (> 6%), in Cox regres- sion analysis, peak atrial longitudinal strain (odds ratio: 0.806, P = .008), Sudden Cardiac Death risk score (odds ratio: 1.114, P = .03) and global longitudinal peak strain (odds ratio: 1.263, P = .02) were found to be independent predictors of occurrence of appropriate ICD therapy., Conclusion: Easily measurable peak atrial longitudinal strain may provide additional information in predicting ventricular arrhythmias or deciding on prophylactic medical treatment to prevent ventricular arrhythmias or reduce the frequency of appropriate shock in high-risk patients with ICD implanted.

Objective: Discontinuation of metformin treatment is a frequently used approach in clinical practice in diabetic ST-segment elevation myocardial infarction patients using metformin in order to reduce the risk of contrast-induced acute kidney injury. There is insufficient evidence in the literature to support this approach. The aim of this study is to determine whether the risk of contrast-induced acute kidney injury is different in diabetic ST-segment elevation myocardial infarction patients using metformin compared to those not taking metformin., Methods: The population of the study consisted of patients who applied to our centers that are covered by this study with the diagnosis of ST-segment elevation myocardial infarction and underwent primary percutaneous intervention between 2014 and 2019. Three forty-three diabetic patients that met the study inclusion criteria were divided into 2 groups as who have been receiving metformin and who have not. Patients' creatinine values at admission and peak creatinine values were compared in order to determine whether they have developed contrastinduced acute kidney injury. The 2 groups were compared using conditional logistic regression analysis conducted with the inverse probability weighting method., Results: Non-weighted classic multivariable logistic regression analysis revealed that metformin use was not associated with acute kidney injury. Weighted conditional multivariable logistic regression revealed that the increase in the risk of acute kidney injury was associated with baseline creatinine levels [odds ratio: 1.49 (1.06-2.10; 95% CI) P=.02] and that the increase in the risk of contrast-induced acute kidney injury was not associated with metformin usage [odds ratio: 0.92 (0.57-1.50, 95% CI) P=.74]., Conclusion: No statistically significant difference was found between the metformin and nonmetformin users among the diabetic ST-segment elevation myocardial infarction patients who underwent primary percutaneous intervention in the risk of contrast-induced acute kidney injury.

Paravalvular leak (PVL) is a complication of valve replacement surgery which may lead to serious clinical consequences including hemolytic anemia. This study aimed to retrospectively evaluate the effect of successful intervention on serum lipid parameters in patients with PVL. A total of 106 patients (mean age: 57.2 ± 13.6 years, male: 67) who underwent surgical or transcatheter closure for symptomatic PVL were enrolled in this study. During the follow-up period, hemolysis and lipid parameters were evaluated at each clinical visit. This is the first study describing the effects of PVL on lipid metabolism after surgical or transcatheter closure. In the study, 18 patients (17%) had aortic PVL, 84 patients (79%) had mitral PVL, and 4 patients (3.8%) had both aortic and mitral PVL. A total of 59 patients underwent transcatheter closure and 47 patients were treated surgically. Technical success of the procedures was 83%. After successful PVL closure, hemoglobin and haptoglobin levels increased significantly (9.5 ± 1.3 vs 11.9 ± 2.1 g/dl, p <0.001 and 16.6 ± 7.9 vs 34.1 ± 19.9 mg, p <0.001, respectively). A significant increase in total cholesterol (158.9 ± 42.7 vs 209.3 ± 58.7 mg/dl, p <0.001), low-density lipoprotein cholesterol (99.1 ± 33.8 vs 133.9 ± 45.7 mg/dl, p <0.001), and high-density lipoprotein cholesterol (39.8 ± 12.4 vs 44.8 ± 11.7 mg/dl, p <0.001) levels was observed after successful PVL closure. In conclusion, symptomatic patients with PVL had hypocholesterolemia, reflected by low serum lipoprotein levels. After successful PVL closure, an increase in serum lipoprotein levels was observed. The recovery in levels of lipoproteins could be used as a marker of successful PVL closure, and absence of recovery of lipoprotein levels may indicate incomplete closure., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Several studies have shown that high uric acid (UA) and low serum albumin (SA) values increase the risk of cardiovascular disease and mortality in ST-elevation myocardial infarction (STEMI). We determined whether the uric acid/albumin ratio (UAR) is a predictor of mortality in STEMI patients. All patients who presented at our center with a diagnosis of STEMI and underwent percutaneous intervention from 2015 to 2020 were screened consecutively; 4599 patients were included. A Cox proportional hazards model was used to evaluate UAR, and adjusted predictors obtained from laboratory findings and clinical characteristics contributed to mortality. Also, a regression model was presented with a directed acyclic graph (DAG). The median age of the patients was 58 years (IQR [interquartile range]: 50-67); 3581 patients (77.9%) were male. The incidence of mortality in the entire patient group was 11.9%. Median follow-up duration of all groups was 42 months. Multivariate Cox proportional regression (model-1) analysis showed age (increase 50 to 67 years; HR [hazard ratio]: 1.34, 95% CI 1.18-1.52) and UAR (increase 1.15-1.73; HR: 1.33, 95% CI 1.16-1.52) were associated with mortality. UAR may be a prognostic factor for mortality in STEMI patients and an easily accessible parameter to identify high-risk patients.

The effect of malnutrition on outcomes after carotid artery stenting (CAS) is not well known. This study reports the relationship between malnutrition and post-procedure 30-day major adverse events (MAEs). A total of 978 patients hospitalized for CAS were enrolled in the study. Controlling nutritional status (CONUT) score, the nutritional risk index (NRI), and the prognostic nutritional index (PNI) were calculated. MAEs (myocardial infarction, stroke/transient ischemic attack and mortality) were compared. According to the CONUT score, NRI, and PNI, 9.4%, 41%, and 11.4% patients were moderately or severely malnourished, respectively; 74.8% were at least mildly malnourished by at least 1 score. Forty-seven patients (4.8%) had a post-procedure 30-day MAE. Continuous classifications of the indexes were independently associated with higher MAE. CONUT showed the highest predictive ability, whereas NRI had the lowest (C-index: CONUT, 0.701; NRI, 0.681; PNI, 0.688). According to categorical classification of indexes, only CONUT and PNI showed predictive ability for MAE. Malnutrition assessment could identify patients with CAS at elevated risk for MAE. CONUT, NRI, and PNI continuous scores were independent prognostic factors for the post-procedure 30-day MAE. According to our study, CONUT showed the highest predictive ability.

Pulmonary artery sarcoma is an extremely uncommon malignancy with a poor prognosis. It is often difficult to distinguish it from pulmonary thromboembolic disease because of nonspe cific signs and symptoms as well as similar imaging findings. We present a 46-year-old man who had initially been diagnosed with presumed asthma that later proved to be pulmonary artery sarcoma. The patient was evaluated with multi-modality imaging studies which showed a mass in the pulmonary artery, its extension, mobility and invasion, and attachment to the artery wall. Pulmonary artery mass was excised and pulmonary artery endarterectomy was performed. The histopathological diagnosis was undifferentiated sarcoma with pleomorphic morphology.

Objective: Endovascular therapy (EVT) has increasingly been used even after the development of new techniques and technologies. EVT has displayed durable early and mid-term outcomes for infrarenal aorta occlusions (IAO). Nonetheless, little is known regarding their long-term outcomes and predictors of restenosis., Methods: A total of 55 consecutive patients (age, 58.8±6.97 years; 67.2% male; 42% critical limb ischemia) from a single-center database, undergoing EVT for IAO disease between January 2011 and March 2019 were retrospectively analyzed. The outcome measures were primary patency rate and amputation free survival calculated by the Kaplan-Meier method. Independent predictors of restenosis were assessed by Cox proportional hazard regression model., Results: In 49 patients (89.1%), technical success was achieved. In total, 190 stents (65 self-expandable stents, 60 balloon-expandable stents) were implanted. During the follow up of 34.5±28 months, 7 patients experienced loss of patency. Primary patency rates were 96%, 82%, and 75% at 1, 3, and 5 years, respectively, and amputation free survival rates were 100%, 90%, and 82% at 1, 3, and 5 years, respectively., Conclusion: In this study, five-year outcomes of primary patency and amputation free survival for EVT of infrarenal aorta total occlusive lesions were favorable. None of the demographic, lesion, and device factors were independently associated with loss of primary patency.

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Objective: The SYNTAX score (SS) is not just a measure of the severity of coronary artery disease, but also complexity. The aim of this study was to evaluate the relationship between the SS and myocardial viability/non-viability assessed by positron emission tomography (PET) in patients with ischemic cardiomyopathy (IC)., Methods: A total of 107 IC patients who had undergone PET were enrolled in the study. The patients were divided into two groups according to the presence or absence of viable myocardium. SS was analyzed from recorded conventional coronary angiographies., Results: Patients with a non-viable myocardium (n=21; 19.6%) had a significantly higher SS compared to those with a viable myocardium (17.6±3.7 vs. 14.1±5.2, respectively; p=0.004). Point-biserial correlation coefficient analysis indicated that the presence of myocardial non-viability was mildly correlated with a higher SS (rpb=-0.28, p=0.004). In multivariate logistic regression analysis, the SS was identified as the sole independent predictor of myocardial non-viability (odds ratio [OR]: 1.164, 95% confidence interval [CI]: 1.044-1.297; p =0.006]. Receiver operating characteristic analysis revealed a cutoff point of 16 for predicting a non-viable myocardium (area under curve: 0.71, 95% CI: 0.61-0.82) with a sensitivity of 76.2% and a specificity of 61.6%., Conclusion: The results of the present study indicates that a high SS is associated with the presence of a non-viable myocardium in IC patients.

Objective: This study aimed to determine the differences in terms of demographic characteristics and preferred stroke prevention strategies for patients with non-valvular atrial fibrillation living in seven geographical regions of Turkey., Methods: In total, 6273 patients were enrolled to this prospective, observational RAMSES study. The patients were divided into seven groups based on the geographical region of residence., Results: In terms of the geographical distribution of the overall Turkish population, the highest number of patients were enrolled from Marmara (1677, 26.7%). All demographic characteristics were significantly different among regions. Preferred oral anticoagulants (OACs) also differed between geographical regions; non-vitamin K OACs were preceded by warfarin in East Anatolia, Aegean, Southeast Anatolia, and Black Sea. Nearly one-third of the patients (28%) did not receive any OAC therapy. However, the number of patients not receiving any OAC therapy was higher in Southeast Anatolia (51.1%) and East Anatolia (46.8%) compared with other geographical regions of Turkey. Inappropriate use of OACs was also more common in East and Southeast Anatolia., Conclusion: This study was the first to show that the demographic differences among the geographical regions may result in different preferences of stroke prevention strategies in Turkey. OACs are still under- or inappropriately utilized, particularly in the eastern provinces of Turkey.

Background and Objectives: Balloon sizing remains the main technique for determining occluder device size for atrial septal defects (ASDs). New evidence has proposed that accurate estimation of device size could be possible without using the balloon technique. Operators have predicted the amount of possible enlargement depending on their experiences. Thus, selection criteria have mostly relied on personal observations and experiences. The objective of this study was to determine the relationship between age, sex, defect size, and deployed device size based on the balloon technique., Subjects and Methods: Sixty-six patients who underwent percutaneous ASD closure with a Cardi-O-Fix occluder between 2011 and 2012 were retrospectively evaluated. Patients whose maximum defect size and device size were available were included. Enlargement amount (EA) (device size-defect size) and enlargement ratio (ER) (EA/defect size) were calculated. The relationship between these 2 calculations and age, sex, and defect size were analyzed., Results: EA and ER were 5.2±3.6 mm (min: 0, max: 15, median: 5) and 39.3%±31.5% (min: 0, max: 125, median: 32), respectively. EA and ER did not differ between genders (p=0.800; p=0.430). EA and ER were not correlated with maximum defect size (p=0.310; p=0.050). EA and ER showed no correlation with age (p=0.970; p=0.640). However when patients were dichomotized based on age 40, ER was significantly lower in older group (p=0.030). Unexpectedly, no difference was observed between the 2 groups in terms of EA (p=0.110). Size of deployed device had a strong correlation with defect size measured with two-dimensional (2D) transesophageal echocardiography (TEE; device size=1.1177×TEE defect size+3.5297; R=0.84; p<0.010)., Conclusion: EA and ER did not show a significant correlation with sex and defect size in our study. Patients older than 40 had a significantly lower ER compared to younger patients. Device size was strongly correlated with defect size measured with TEE., Competing Interests: Conflict of Interest: The authors have no financial conflicts of interest.

Background: The data regarding stroke prevention strategies in nonvalvular atrial fibrillation (NVAF) are limited especially in patients with renal impairment (RI). We sought to evaluate management dilemmas in patients with concurrent NVAF and RI in RAMSES (ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies inTurkey) study., Methods: We conducted a prospective, multicenter, nation-wide registry in NVAF patients in outpatient cardiology clinics. All consecutive patients with NVAF were enrolled in RAMSES study (ClinicalTrials.gov identifier NCT02344901). The baseline data were collected. Glomerular filtration rate (GFR) was estimated by Cockcroft-Gault equation., Results: A total number of 6273 patients from 29 provinces of Turkey with the contribution of 83 investigators were enrolled to the study. Of the study population, 1964(33%) patients had RI which was defined as GFR < 60 mL/min. Patients with RI had significantly higher CHA 2 DS 2 VASc and HAS-BLED scores compared to those without RI (3·9 ± 1·5 vs. 2·9 ± 1·5, and 2·0 ± 1 vs. 1·4 ± 1; P < 0·001). Prior history of major bleeding (6·9% vs. 4·1%, P < 0·001) and stroke (16·2% vs. 11·8%, P < 0·001) was significantly higher among individuals with concomitant RI and NVAF. Although RI patients had a higher risk for thromboembolism, number of the patients who did not receive any anticoagulant therapy was higher in patients with RI than without RI (30·1 vs. 26·4%, P = 0·003)., Conclusion: RAMSES study showed that one-third of the patients with NVAF had RI in the real-world setting. Although it is mandatory in most of the patients with concomitant NVAF and RI, nearly one-third of these patients did not receive any anticoagulant therapy., (© 2017 Stichting European Society for Clinical Investigation Journal Foundation.)

Objective: No studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies., Methods: Baseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared., Results: Of the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8±9.8 vs. 68.7±11.4years, p<0.001), had a lower socioeconomic status, had a higher CHA 2 DS 2 VASc and HASBLED scores (3.4±1.4 vs. 3.1±1.7, p<0.001 and 1.7±1.0 vs. 1.6±1.1, p<0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p<0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p<0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p<0.001)., Conclusion: This study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs., (Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objectives: Aim of the present study was to investigate correlation between left atrial (LA) deformation parameters assessed using 2-dimensional (2D) speckle tracking echocardiography (STE) and complexity of coronary artery disease according to SYNTAX score (SXscore) in patients with stable coronary artery disease (SCAD)., Study Design: Total of 60 moderate-risk SCAD patients (40 men, 20 women) who underwent coronary angiography and 30 healthy controls were included. Measurements of conventional echocardiographic parameters as well as peak LA strain during ventricular systole (LA-RES), peak LA strain during atrial systole (LA-PUMP), peak LA strain rate during ventricular systole (LA-SRS), peak LA strain rate during early diastole (LA-SRE), and peak LA strain rate during atrial systole (LA-SRA) were obtained., Results: Patients were categorized into 2 groups: low SXscore of <20 (Group I) and high SXscore of ≥20 (Group II). Left ventricular (LV) diastolic functions were significantly impaired and LV filling pressure was significantly higher in high SXscore group. LA-RES (Control Group: 42.3±7.9, Group I: 36.4±8.2, Group II: 27.5±8.1; p<0.001) and LA-PUMP (Control Group: 17.6±3.4, Group I: 15.7±2.5, Group II: 13.1±3.2; p<0.001) were significantly lower in high SXscore group compared with low SXscore group. There was no statistical difference in LA-SRS, LA-SRE, or LA-SRA between the 3 groups. Correlation analysis indicated negative correlation between SXscore level and LA-RES function (r=-0.49; p<0.001)., Conclusion: 2D-STE-based LA deformation parameters are significantly impaired in patients with SCAD who have high SXscore. In addition, evaluation of LA-RES and LA-PUMP functions might be useful in estimating severity of disease in patients with SCAD.

The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA 2 DS 2 VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA 2 DS 2 VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.

Objective: Gender is an important feature in the management of atrial fibrillation (AF). This study investigated gender-related differences in patients with AF in Turkey., Methods: As a part of RAMSES (ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey, NCT02344901) study, information of the patients with AF who successively applied to the hospital was analyzed. This cross-sectional, multicenter, nationwide observational study enrolled 6264 non-valvular AF (NVAF) outpatients (55.9% women) from Turkey., Results: Compared with men, women with NVAF were older (71 years [range: 65-78 years] vs. 70 years [range: 62-77 years]; p<0.001), had lower frequency of coronary artery disease (22.0% vs. 38.3%; p<0.001) and congestive heart failure (18.2% vs. 27.2%; p<0.001). Women had higher median CHA2DS2-VASc score (4 [range: 3-5] vs. 3 [range: 2-4]; p<0.001), but similar HAS-BLED score (2 [range: 1-2] vs. 2 [range: 1-2]; p=0.141) when compared with men. Anticoagulant therapy use was higher in women (74.5% vs. 69.9%; p<0.001). Analysis of anticoagulation therapy use revealed that 68.5% of men and 61.6% of women (p=0.204) who had low risk for stroke (CHA2DS2-VASc score: 0 [male], 1 [female]) received anticoagulation therapy, and 30.5% of the men. Meanwhile, 25.3% of the women (p<0.001) with high risk for stroke (CHA2DS2-VASc score: ≥1 [male], ≥2 [female]) had not received any anticogulant therapy., Conclusion: Although women with NVAF receive better treatment than men, anticoagulation therapy is suboptimal in large proportion of men and women, with underuse in high-risk patients and overuse in low-risk patients. There is an urgent need to improve optimization of anticoagulation in patients with NVAF.

Background: Parameters derived from complete blood count, such as mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), have recently been proposed as measures of inflammation in addition to C-reactive protein (CRP), a classical inflammatory marker. Significant association of these parameters with atherosclerosis and complications have increasingly been reported., Aim: The aim of the study is to evaluate the relationship between these parameters and the presence of myocardial viability assessed with positron emission tomography (PET) in patients with ischaemic cardiomyopathy (ICM)., Methods: A total of 122 ICM patients who had undergone PET were enrolled in this study. The patients were dichotomised depending on the presence of transmural scar. Group 1 consisted of 21 patients who had transmural scar tissue only, who were accepted as the group having non-viable myocardium. Group 2 consisted of 101 patients who had hibernation and/or non-transmural scar, who were accepted as the group having viable myocardium. Haematological parameters within 30 days of PET imaging were retrospectively analysed., Results: There were no significant differences between the two groups regarding values of white blood cell, neutrophil, lymphocyte, platelet, haemoglobin, red cell distribution width, CRP, PLR, and NLR. Patients with non-viable myocardium have significantly higher levels of MPV (p = 0.002). In multiple logistic regression analysis, MPV (odds ratio [OR] = 0.373, 95% confidence interval [CI] 0.20-0.69, p = 0.002), was identified as an independent predictor of non-viable myocardium. In receiver-operator characteristic (ROC) analysis, a cut-point of 8.19 identified patients with non-viable myocardium (area under curve: 0.72, 95% CI 0.60-0.84). An MPV value greater than 8.19 demonstrated a sensitivity of 76% and a specificity of 55%. \ CONCLUSIONS: The present study showed that MPV is an inexpensive, clinical, and routinely measurable parameter that is associated with the presence of viable myocardium in ICM.

Background/aim: The aim of this study was to evaluate if the modified ACEF (age, creatinine, and ejection fraction) score is a predictor of major adverse cardiac and cerebrovascular events during 1 year of follow-up in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI)., Materials and Methods: We retrospectively enrolled 1632 consecutive patients who were admitted to our emergency department diagnosed with STEMI within 12 h of chest pain and treated with primary PCI. The modified ACEF score, determined with a simplified scoring system, was calculated. The patients were grouped into tertiles according to this score (group I mACEF < 1.03, group II mACEF 1.03-1.37, group III > 1.37) . The clinical and angiographic data were compared among the tertiles., Results: In patients with the highest mACEF tertile, out-of-hospital cardiac arrest (1.3%, 1.8%, and 4.1% consecutively; P = 0.003), Killip class &ge; II (P < 0.001), and cardiogenic shock were more common and ejection fraction was lower (P < 0.001). Moreover, in the 1-year follow-up, there was a statistically significant difference between cardiac mortality, target vessel revascularization, stroke, reinfarction, and major adverse cardiac and cerebrovascular events of the groups, while the rates of stent thrombosis were similar., Conclusion: The modified ACEF score is a predictor of cardiac mortality and morbidity during 1-year follow-up.

Objective: Mitral valve regurgitation (MR) is the second most common heart valve disease in Europe. Without intervention, prognosis of severe symptomatic MR is poor. Percutaneous edge-to-edge mitral valve repair with MitraClip is a promising mitral regurgitation treatment technique in select, high-surgical-risk patients. The present objective was to describe the experience of a single center with MitraClip use in a high-risk series in Turkey., Methods: Between May 2013 and September 2014, 28 high-surgical-risk patients with MR of at least grade 3+ and mean EuroSCORE of 26% underwent MitraClip implantation at our institution. In-hospital and follow-up safety and efficacy results are presented., Results: Mean patient age was 58 years, and 75% were male. Grade 3 or 4 MR was present in all patients, and was primarily the result of restrictive functional mitral regurgitation (in 89% of cases). Mean left ventricular ejection fraction (LVEF) was 27% and New York Heart Association (NYHA) classification was III or IV in 89% of the population. Acute procedural success was 89%, with 47% of patients receiving a single clip, 39% receiving 2 clips, and 14% receiving 3 clips. One periprocedural death occurred, and 2 deaths occurred during follow-up (mean: 13.9 months). After 1 year, more than 75% of patients had MR severity of ≤2+ and NYHA classification of I or II, but no significant change in left ventricular volume or systolic function. Significant improvement in 6-minute walk test and quality of life was also observed., Conclusion: Initial experience with the MitraClip system showed promising results in patients considered high-surgical-risk, particularly in those with end-stage heart failure.

Objective: Data regarding stroke prevention strategies in non-valvular atrial fibrillation (NVAF) are limited to vitamin K antagonists (VKAs). This study aimed to evaluate real-life stroke prevention strategies for NVAF patients in the era of non-VKA oral anticoagulants (NOACs)., Methods: We established a cross-sectional, multicenter, nationwide registry of NVAF patients. All consecutive atrial fibrillation (AF) patients and without mechanical heart valves or rheumatic mitral stenosis (but including those with any degree of mitral regurgitation) were enrolled in the ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies (RAMSES Study; ClinicalTrials.gov identifier NCT02344901) in Turkey. Baseline demographic data, medical history, and medications prescribed for NVAF treatment were collected. Univariate analyses were performed for continuous variables, and the chi-square test was used for categorical variables., Results: In total, 6273 patients from 29 provinces of Turkey were enrolled in the study between February and May 2015, with the contribution of 83 investigators. The mean age was 69.6±10.7 years; 56% of the patients were females, and one-fifth of the patients had at least one comorbid disease, the most common being hypertension (69%). The mean CHA2DS2-VASc and HAS-BLED scores were 3.3±1.6 and 1.6±1.1, respectively. The rate of oral anticoagulant (OAC) therapy use was 72% (37% NOAC and 35% VKA)., Conclusion: The RAMSES study showed a higher prevalence of OAC use among NVAF patients than that reported in previous studies. Although NOACs were preferred over VKAs in daily cardiology practice, there is a need for improved OAC therapies for NVAF patients.

Objective: Atrial fibrillation is the most common arrhythmia and is associated with a five- fold increased risk of thromboembolic events. Vitamin K antagonists (VKAs) have been the mainstay of oral anticoagulant prophylaxis and the data on stroke prevention strategies are limited to VKA era. The purpose of this study is to evaluate the use of VKA, non-Vitamin K antagonist oral anticoagulants (NOAC), and antiplatelet agents in patients with non-valvular atrial fibrillation (NVAF)., Methods: The ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey (RAMSES) is an observational, multicenter, prospective study of patients with NVAF. The study targeted enrollment of 7835 patients from 68 sites in Turkey. All the data will be collected at one point in time and current clinical practice will be evaluated. (ClinicalTrials.gov number NCT02344901)., Results: Baseline characteristics of patients, antithrombotic therapies, transition to NOACs and rate/rhythm control strategies will be evaluated., Conclusion: The RAMSES registry will be the largest study in Turkish NVAF patients. The study will provide insights into real-world problems and anticoagulant treatment in patients with NVAF.

Objective: The aim of this study was to determine the role of left-sided mechanical parameters in postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting (CABG)., Methods: Ninety patients with coronary artery disease and normal left ventricular (LV) function in sinus rhythm were enrolled in the study. Preoperative LV and left atrial (LA) mechanics were evaluated by two-dimensional (2D) speckle-tracking echocardiography (STE), including strain and rotation parameters, and volume indices. Patients were monitored in order to detect POAF during the postoperative period., Results: Twenty-three of 90 patients (25.6%) developed POAF. Age (p<0.001) and preoperative beta blocker usage (p=0.001) were the clinical parameters associated with POAF. Left atrial maximum volume index (LAV[max]i) increased, and peak left atrial longitudinal strain (PALS) was impaired in POAF patients (p=0.001, p<0.001, respectively). Left ventricular twist (LVtw) and left ventricular peak untwisting velocity (UntwV) were augmented in POAF patients (p=0.013, p=0.009, respectively). Receiver operating characteristic analysis showed N-terminal pro-brain natriuretic peptide (NT-proBNP) levels above 70 pg/ml and predicted POAF with a sensitivity of 74% and specificity of 78% (area under curve: 0.758, 95% confidence interval [CI] 0.631-0.894, p<0.001). Logistic regression analysis demonstrated that age (odds ratio [OR] 1.1, CI 1.01-1.20, p=0.034), preoperative beta blocker usage (OR 8.84, CI 1.36-57.28, p=0.022), NT-proBNP (values >70 pg/ml, OR 22.377, CI 3.286-152.381, p<0.001), PALS (OR 0.86, CI 0.75-0.98, p=0.023), and UntwV (OR 1.02, CI 1.00-1.04, p=0.029) were the independent predictors of POAF., Conclusion: The combination of 2D STE, clinical, and biochemical parameters may help predict POAF.

Objective: The present study was designed to determine the effects of tirofiban (Tiro) infusion on angiographic measures, ST-segment resolution, and clinical outcomes in patients with STEMI undergoing PCI. Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI), while the most effective timing of administration is still under investigation., Methods: A total of 1242 patients (83.0% males, mean (standard deviation; SD) age: 54.7 (10.9) years) with STEMI who underwent primary PCI were included in this retrospective non-randomized study in four groups, composed of no tirofiban infusion [Tiro (-); n=248], tirofiban infusion before PCI (pre-Tiro; n=720), tirofiban infusion during PCI (peri-Tiro; n=50), and tirofiban infusion after PCI (post-Tiro; n=224). In all Tiro (+) patients, bolus administration of Tiro (10 µg/kg) was followed by infusion (0.15 µg/kg/min) for a mean (SD) duration of 22.4±6.8 hours., Results: The pre-PCI Tiro group was associated with the highest percentage of patients with TIMI 3 flow (99.4%; p<0.001), the lowest corrected TIMI frame count [21(18-23.4); p<0.001], the highest percentage of patients with >75% ST-segment resolution (78.1%; p<0.001), and the lowest rate of in-hospital sudden cardiac death and in-hospital all-cause mortality (3.2%, p<0.05, 3.3%, p=0.01). Major bleeding was reported in 18 (1.8%) patients who received tirofiban., Conclusion: Use of standard-dose bolus tirofiban in addition to aspirin, high-dose clopidogrel, and unfractionated heparin prior to primary PCI significantly improves myocardial reperfusion, ST-segment resolution, in-hospital mortality rate, and in-hospital sudden cardiac death in patients with STEMI with no increased risk of major bleeding.

Objective: Slow coronary flow (SCF) phenomenon is described as the delayed opacification of the distal vasculature and angiographically normal coronary arteries. Considerable studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tpe) may correspond to the transmural dispersion of repolarization and that increased Tpe interval and Tpe/QT ratio are associated with malignant ventricular arrhythmias. In this study, we intended to evaluate ventricular repolarization in patients with SCF by using the Tpe interval and Tpe/QT ratio., Methods: The study population included 33 patients with angiographically proven SCF and 33 control patients with angiographically proven normal coronary arteries without associated SCF. Coronary flow rates of patients and the control group were documented by TIMI (Thrombolysis in Myocardial Infarction) frame count. From the electrocardiograms, Tpe interval and Tpe/QT ratio were calculated and compared between groups., Results: No statistically significant difference was found between the two groups in terms of basic characteristics. Mean Tpe interval, Tpe/QT ratio, and Tpe/QTc ratio were prolonged in the study group compared to the control group (p<0.001)., Conclusion: Tpe interval and Tpe/QT ratio were increased in SCF patients.

Although the effects of chronic alcoholism on left ventricular (LV) systolic function are well established, diastolic impairment has been evaluated partially. In addition, there are scarce data available about the relation of LV diastolic function to either or both duration and quantity of drinking among alcoholics. The aim of the study was to evaluate the left atrial (LA) function in chronic asymptomatic alcoholic patients by using two-dimensional speckle-tracking echocardiography (2D-STE). We enrolled 30 healthy subjects (age 34.8 ± 5.8 years) and 75 asymptomatic male alcoholics (age 39.8 ± 6.5 years) divided into two groups, according to total lifetime dose of ethanol: group I, <15 kg/kg and group II, ≥15 kg/kg. In the 2D-STE analysis of the LA, strain during ventricular systole (LA-Res), during late diastole (LA-Pump) and strain rate during ventricular contraction (LA-SRs), during passive ventricular filling (LA-SRe), during active atrial contraction (LA-SRa) were obtained. Deceleration time was longer, E/A and V(p) were smaller, and E/E(m) was higher in alcoholics. Although parameters of diastolic dysfunction were comparable in alcoholic groups, LA-Res and LA-Pump were found significantly different among the alcoholics. However, there were no differences in LA-SRs and LA-SRe between the controls and alcoholic groups. LA function is reduced in chronic alcohol abuse, and heavy alcohol consumption may play an important role in LA function impairment.

Percutaneous edge-to-edge mitral valve repair using the MitraClip (Abbot Vascular, USA) system is a promising technique for mitral regurgitation treatment in select high-risk surgical patients. Although the safety and efficacy of the technique have been demonstrated, a few complications of the MitraClip device have been reported. In this report, we present a rare complication that recently occurred during the performance of a MitraClip procedure in a patient with severe functional mitral regurgitation. One MitraClip arm got stuck inside the guide catheter in the left atrium and a decision was made to discontinue percutaneous intervention because the problem could not be resolved.