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Eventhough acute carotid stent thrombosis is a rare complication of carotid arterystenting (CAS), it can cause fatal thromboembolic events. There are limitednumbers of techniques that can be applied during such emergencies. In thisstudy, we report a case in which the sandwich technique was successfullyperformed in the acute in-stent thrombosis. Conclusively, in-proceduralin-stent thrombosis following CAS must be rapidly evaluated and treated,allowing the efficient prevention of catastrophic events. Thus, sandwich stenttechnique is a rapid and efficient method for treating acute in-stentthrombosis., Akutkarotis arter stent (KAS) trombozu nadir bir komplikasyon olmasına rağmen fataltromboembolik olaylara neden olabilir. Akut olaylarda uygulanabilecek sınırlısayıda teknik olmakla birlikte bu olgu bildirimizde akut KAS trombozunda başarılıbir şekilde uygulanan “sandviç stent tekniğini” sunmaktayız. Prosedürel akutKAS trombozu hızlı ve etkin bir şekilde değerlendirilerek tedavi edilmesigereken bir durumdur. Bu olgumuzda kullandığımız teknik böyle katastrofikdurumlarla başetmede hızlı ve güvenli alternatif bir yöntem olarakkullanılabilir.

It is of clinical importance to determine creatinine clearance and adjust doses of prescribed drugs accordingly in patients with heart failure to prevent untoward effects. There is a scarcity of studies in the literature investigating this issue particularly in patients with heart failure, in whom many have impaired kidney function. The purpose of this study was to determine the degree of awareness of medication prescription as to creatinine clearance in patients hospitalized with heart failure. Patients hospitalized with a diagnosis of heart failure were retrospectively evaluated. Among screened charts, patients with left ventricular ejection fraction

Takotsubo cardiomyopathy (TCMP) is characterised by a temporary aneurysm of the left ventricular apex in individuals without significant stenosis of the coronary arteries. It is extremely rare to see it combined with a thrombus. In this case report, we present a 57-year-old female patient with TCMP in whom apical thrombus was treated with short-term warfarin use.

Recent studies have reported that a novel cardiac biomarker, heart-type fatty acid-binding protein (h-FABP), significantly predicts mortality inpatients with pulmonary embolism (PE) at intermediate risk. The aim of this study was to evaluate the effect of thrombolytic therapy on prognosis of the intermediate risk acute PE patients with elevated levels of h-FABP. This is non-interventional, prospective, and single-center cohort study where 80 patients (mean age 62 ± 17 years, 32 men) with confirmed acute PE were included. Only patients with PE at intermediate risk (echocardiographic signs of right ventricular overload but without evidence for hypotension or shock) were included in the study. h-FABP and other biomarkers were measured upon admission to the emergency department. Thrombolytic (Thrl) therapy was administered at the physician’s discretion. Of the included 80 patients, 24 were h-FABP positive (30 %). 14 patients (58 %) with positive h-FABP had clinical deterioration during the hospital course and required inotropic support and 12 of these patients died. However, of 56 patients with negative test, only 7 patients worsened or needed inotropic support and five patients died during the hospital stay. Mortality of patients with PE at intermediate risk was 21 %. The 30-day mortality rate was significantly higher in h-FABP(+) patients compared to h-FABP(−) patients (9 vs. 50 %, p < 0.001). Multivariate analysis revealed h-FABP as the only 30 day mortality predictor (HR 7.81, CI 1.59–38.34, p = 0.01). However, thrl therapy did dot affect the survival of these high-risk patients. Despite, h-FABP was successful to predict 30-days mortality in patients with PE at intermediate risk; it is suggested to be failed in determining the patients who will benefit from thrl therapy.

Background Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance encountered in clinical practice and is associated with impaired quality of life. Data from the previous studies have shown that sleep quality (SQ), as a component of life quality, may also deteriorate in patients with AF. However, it remains unclear; we do not know whether SQ improves after sinus rhythm is maintained. Therefore, we aimed to examine the relationship between SQ and AF, as well as the effects of sinus rhythm restoration with direct current cardioversion (DCC) on SQ among patients with persistent AF. Methods One hundred fifty-three patients with a diagnosis of nonvalvular AF and 150 age-matched control subjects with sinus rhythm were recruited. SQ was assessed using the Pittsburgh Sleep Quality Index (PSQI). The study was designed with two stages. First, the difference in SQ between AF patients and age-matched controls was examined. Patients with global PSQI scores greater than 5 were defined as “poor sleepers.” Thus, a higher global PSQI score indicated worsened SQ. Predictors of poor SQ were also analyzed using a regression model. Second, the effect of rhythm control on SQ was studied in patients with AF who were eligible for DCC. Of the 65 patients with persistent AF, 54 patients with successful cardioversion were followed for 6 months. The remaining 11 patients, whose cardioversion was unsuccessful, were not followed. After 6 months of follow-up, the PSQI scores of patients with sinus rhythm maintenance (n = 39) and patients with AF recurrence (n = 15) were reassessed. Changes in global PSQI scores (baseline vs after 6 months) were analyzed. Results The PSQI scores were significantly higher in the AF group compared to the control group (9.4 ± 4.6 vs 5.8 ± 4.1, P = 0.001, respectively). The prevalence of poor sleepers was significantly higher in the AF group (76%) than in the control group (45%) (P < 0.001 by the χ2 test). Multivariate logistic regression analysis showed that AF (odds ratio [OR]: 3.36, 95% confidence interval [CI]: 2.00–5.55), age (OR: 1.02, 95% CI: 1.00–1.04), and diabetes mellitus (OR:1.79, 95% CI: 1.03–3.14) were independent predictors of poor SQ. In the second stage, the effect of rhythm control on the SQ of the 54 patients with successful DCC was analyzed. PSQI scores improved significantly between baseline and the 6 months in sinus rhythm maintenance group (8.7 ± 4.1 vs 7.2 ± 3.8, P < 0.001, respectively). However, in the AF recurrence group, the change in global PSQI scores between baseline and the sixth month was not statistically significant (9.8 ± 4.5 vs 9.2 ± 4.2, P = 0.56, respectively). Conclusion Patients with AF have shorter sleep duration and poor SQ. Maintenance of sinus rhythm after DCC may have a favorable effect on the SQ of patients with AF. Nevertheless, AF is an independent predictor of poor SQ.

OBJECTIVE: Strain and strain rate imaging is currently the most popular echocardiographic technique that reveals subclinical myocardial damage. There are currently no available data on this imaging method with regard to assessing right ventricular involvement in anterior myocardial infarction. Therefore, we aimed to evaluate right ventricular regional functions using a derived strain and strain rate imaging tissue Doppler method in patients who were successfully treated for their first anterior myocardial infarction. METHODS: The patient group was composed of 44 patients who had experienced their first anterior myocardial infarction and had undergone successful percutaneous coronary intervention. Twenty patients were selected for the control group. The right ventricular myocardial samplings were performed in three regions: the basal, mid, and apical segments of the lateral wall. The individual myocardial velocity, strain, and strain rate values of each basal, mid, and apical segment were obtained. RESULTS: The right ventricular myocardial velocities of the patient group were significantly decreased with respect to all three velocities in the control group. The strain and strain rate values of the right mid and apical ventricular segments in the patient group were significantly lower than those of the control group (excluding the right ventricular basal strain and strain rate). In addition, changes in the right ventricular mean strain and strain rate values were significant. CONCLUSION: Right ventricular involvement following anterior myocardial infarction can be assessed using tissue Doppler based strain and strain rate. © 2013 CLINICS.

Background We aimed to investigate the circadian rhythm on left ventricular (LV) function and infarct size, according to the onset of ST elevation myocardial infarction (STEMI), with echocardiography in patients with first STEMI successfully revascularised with primary percutaneous coronary intervention (PCI). Methods We conducted a retrospective analysis of 252 STEMI patients. Patients were divided into the four, six-hour periods of the day. Conventional and tissue Doppler imaging (TDI) echocardiography were performed within 48hours after onset of chest pain. The average of peak systolic myocardial velocities (Sm) in each of the four myocardial segments and LV ejection fraction (LVEF) were calculated. Results A negative linear correlation was shown between CK-MB levels and Sm (r= -0.209, p=0.001). There was an oscillation between time of day and average of Sm. The lowest Sm and largest infarct size were in the period of 06:00-noon compared with period of noon-18:00 and 18:00-midnight (p=0.029 and p=0.031, respectively). A secondary analysis showed that both LVEF and Sm were lower in the midnight-noon group compared with the noon-midnight group (44.9±7.3% versus 47.3±7.9%, p=0.018, and 7.6±1.4cm/s versus 8.2±1.6cm/s, p=0.003, respectively). Conclusions This study has shown that there was a circadian rhythm of infarct size and LV function evaluated by echocardiography according to time of STEMI onset. The largest infarct size and poor LV function occurred in the midnight-noon period, in particular in the 06:00-noon period.

Background: Cigarette smoking is associated with increased rates of coronary artery disease and acute myocardial infarction (MI). Paradoxically, smokers had lower mortality after MI. The purpose of this study was to evaluate the effect of chronic smoking on myocardial performance index (MPI) in middle-aged men after an acute MI. Material and methods: A total of 429 patients (325 smokers vs. 104 nonsmokers) presenting with acute ST elevation MI were enrolled in this study. Thrombolysis in myocardial infarction (TIMI) flow of the infarct related artery was measured before and after the primary percutaneous coronary intervention (PCI), and Gensini score was also calculated. Conventional echocardiography and tissue Doppler echocardiography (TDI) were performed within 48–72 hours after onset of chest pain. Peak early (Em) and late (Am) diastolic velocities, peak systolic (Sm) mitral annular velocities and time intervals were recorded with TDI. The MPI, ratio of Em/Am, and E/Em were calculated. Results: Baseline demographic and angiographic characteristics such as Gensini score, pre and, post PCI TIMI flow were similar in 2 groups. In contrast, LV MPI was preserved among smokers (0.59 ± 0.15 vs. 0.66 ± 0.14, P = 0.01), and Em/Am values were also higher in smokers (0.84 ± 0.28 vs. 0.75 ± 0.31, P = 0.01). Independent predictors of impaired MPI (≥0.60) were determined as nonsmoking status (odds ratio 2.940, 95% CI 0.98–5.83, P = 0.05), left anterior descending artery stenosis (odds ratio 3.196, 95% CI 1.73–5.91 P = 0.001), and, age (odds ratio 1.12, 95% CI 1.03–1.22, P = 0.01). Conclusions: Despite similar demographic and angiographic characteristics, smoker males had a paradoxically better MPI after acute MI.

Increased sympathetic activity and endothelial dysfunction are the proposed mechanisms underlying exaggerated blood pressure response to exercise (EBPR). However, data regarding heart rate behavior in patients with EBPR are lacking. We hypothesized that heart rate recovery (HRR) could be impaired in patients with EBPR. A total of 75 normotensive subjects who were referred for exercise treadmill test examination and experienced EBPR were included to this cross-sectional case–control study. The control group consisted of 75 age- and gender-matched normotensive subjects without EBPR. EBPR was defined as a peak exercise systolic blood pressure (BP) ≥210 mmHg in men and ≥190 mmHg in women. HRR was defined as the difference in HR from peak exercise to 1 min in recovery; abnormal HRR was defined as ≤12 beats/min. These parameters were compared with respect to occurrence of EBPR. Mean values of systolic and diastolic BP at baseline, peak exercise, and the first minute of the recovery were significantly higher in the subjects with EBPR. Mean HRR values were significantly lower (P < 0.001) in subjects with EBPR when compared with those without. Pearson’s correlation analysis revealed a significant positive correlation between the decrease in systolic BP during the recovery and degree of HRR in individuals without EBPR (r = 0.42, P < 0.001). Such a correlation was not observed in subjects with EBPR (r = 0.11, P = 0.34). The percentage of abnormal HRR indicating impaired parasympathetic reactivation was higher in subjects with EBPR (29 % vs 13 %, P = 0.02). In logistic regression analyses, HRR and resting systolic BP were the only determinants associated with the occurrence of EBPR (P = 0.001 and P < 0.001, respectively). Decreased HRR was observed in normotensive individuals with EBPR. In subjects with normal BP response to exercise, a linear correlation existed between the degree of HRR and decrease in systolic BP during the recovery period. However, such a correlation was not found in subjects with EBPR. Our data suggest that mechanisms underlying the blunting of the HRR might be associated with the genesis of EBPR. The association between the extent of HRR and adverse cardiovascular outcomes in patients with EBPR needs to be investigated in detail in future research.

Background: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (Pd) might be a useful marker in predicting PAF in patients with acute ischemic stroke.Methods: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared.Results: Maximum P-wave duration (p=0.002), Pd (pd was the only independent predictor of PAF. The cut-off value of Pd for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (pConclusion: Pd on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

Objectives This study investigated the appropriateness of treatment for patients admitted with ST-segment elevation myocardial infarction (STEMI) according to the current guidelines. We also aimed to determine in-patient and out-patient factors affecting optimal reperfusion therapy. Study design The reperfusion therapy of 176 patients with STEMI was determined. The time period from first contact with a healthcare provider to the time of balloon inflation (door to balloon time), and from the time period of first contact with a healthcare provider to the time of initiation of a thrombolytic (door to needle time) were calculated. Similarly, the time from admission at the emergency service (ES) of our hospital after referral to the moment of balloon inflation (ES to balloon time) and the period from admission to ES at our hospital to the moment of initiation of a thrombolytic (ES to needle time) were calculated. In order to determine the amount of in-hospital delay, the time from ES admission to the call to the cardiology department and the time for the cardiologist to evaluate the patient and transfer time were recorded. Whether the referring physician was a cardiologist and the effect of work hours on the reperfusion period was also recorded. Results The door to balloon time in the referred patient group was calculated as an average of 228 minutes, while the time for patients directly admitted to ES was calculated as an average of 98 minutes. Patients referred for the mechanical reperfusion period compared to American Heart Association (AHA) guidelines consisted of only 6% of the eligible patients, while according to the European Society of Cardiology (ESC) guidelines 13% of patients were appropriate. Patients who were directly admitted to ES, experienced rates according to AHA guidelines and 73% experienced these rates according to ESC guidelines. We also found no significant effect of working hours or referring physician's specialty (cardiologist or other) on reperfusion time. Conclusion Compliance rates of reperfusion therapy for patients presenting with STEMI was very low. We realized, when taking into consideration the reasons for delay in terms of both health community and the policy of the country, it is obvious that we have to take strict measures.

WOS: 000309036000005, PubMed: 22825896, Background: Doxorubicin is a chemotherapeutic agent used in a wide spectrum of cancers. However, cardiotoxic effects have limited its clinical use. The early detection of doxorubicin-induced cardiotoxicity is crucial. The purpose of our study was to assess values of Doppler and tissue Doppler imaging (TDI) -derived myocardial performance index (MPI) in adult cancer patients receiving doxorubicin treatment. Methods: A total of 45 patients underwent echocardiographic examinations before any doxorubicin had been administered and then after doxorubicin. Doppler and TDI-derived MPI of left ventricular (LV) were determined in the evaluation of cardiotoxicity. Additionally, TDI-derived MPI of right ventricular (RV) was determined. Results: All patients underwent control echocardiographic examination after mean 5 +/- 1.7 months. The LV MPI obtained by both Doppler and TDI were increased after doxorubicin treatment (0.56 +/- 0.11, 0.61 +/- 0.10, p = 0,005 vs 0.51 +/- 0.09, 0.59 +/- 0.09, p = 0.001, respectively). There was no correlation between Doppler-derived MPI and cumulative doxorubicin dose (coefficient of correlation 0.11, p = 0.6). TDI-derived MPI was correlated with cumulative doxorubicin dose (coefficient of correlation 0.35, p = 0.015), but this correlation is weak (r = 0.38). The study population was divided into two groups according to doxorubicin dose (below and above 300 mg level). There was a moderate correlation between TDI-derived MPI and less than 300 mg of doxorubicin dose (coefficient of correlation 0.51, p = 0.028). However, Doppler-derived MPI was not correlated with less than 300 mg of doxorubicin dose (coefficient of correlation 0.38, p = 0.123). Also, there was no significant change in the TDI-derived RV-MPI (0.49 +/- 0.14, 0.50 +/- 0.12, p = 0.56). Conclusions: TDI-derived MPI is a useful parameter and an early indicator compared with Doppler-derived MPI in the detection of cardiotoxicity during the early stages. Also, doxorubicin administration does not affect RV function. (Cardiol J 2012; 19,4: 363-368)

WOS: 000301065000003, PubMed: 22211098, Background: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P-d) might be a useful marker in predicting PAF in patients with acute ischemic stroke. Methods: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared. Results: Maximum P-wave duration (p=0.002), P-d (p

CD40 ligand is a thromboinflammatory molecule that predicts cardiovascular events. Platelets constitute the major source of soluble CD40 ligands (sCD40L), which has been shown to influence platelet activation. The main aim of this study was to evaluate sCD40L levels in patients with acute pulmonary embolism (PE). Sixty-five PE patients (32 males, mean age 58 ± 12 years) and 29 healthy controls (15 males, mean age 56 ± 14 years) were enrolled in the study. sCD40L levels were evaluated at the enrollment by ELISA method. Multislice detected pulmonary computed tomography was performed on all patients with a suspected diagnosis of PE. In addition, echocardiography was performed to evaluate right ventricular (RV) dysfunction. There was no statistically significant difference between the two groups regarding demographic features. sCD40L levels were significantly higher in acute PE group compared to healthy controls (5.3 ng/ml and 1.4 ng/ml, respectively; p < 0.001). sCD40L levels of patients with and without RV dysfunction were similar. Correlation analysis between echocardiographic findings and sCD40L levels did not show significant difference. The present study demonstrated a role of sCD40L in pathogenesis of PE for the first time. Further studies are needed to clarify a predictive and prognostic value of sCD40L levels in acute PE patients.

The goal of the study described here was to evaluate interictal heart rate variability (HRV) in young patients with epilepsy, a patient population in whom sudden unexpected death in epilepsy (SUDEP) is known to be more common.Twenty-four-hour ambulatory ECG Holter recordings of 37 patients (15-40 years old) and 32 healthy controls were compared.All of the time domain indices (SDNN, SDANN, RMSSD, and HRV triangular index) were significantly suppressed (P0.001), and there was a marked reduction in parasympathetic tone (reduced HF(nu,)P0.001) and an increase in sympathetic tone (increased LF(nu) and LF/HF ratio, P0.001) in the patient group. Stepwise linear regression analysis revealed that polytherapy and epilepsy duration10 years were independent variables associated with a reduction in SDNN.Our data suggest that the major determinants of suppressed SDNN are polytherapy and epilepsy duration10 years. Analysis of spectral measures of frequency domain indices suggests that an increased sympathetic tone in association with a decreased parasympathetic tone may constitute the mechanism underlying SUDEP in young people with epilepsy.

Atrial remodeling is an important part of cardiac remodeling after acute myocardial infarction (AMI). The aim of this study was to evaluate the effect of spironolactone on atria in patients with preserved left ventricular (LV) functions after AMI by using two-dimensional and tissue Doppler imaging techniques (TDI).The study consisted of 110 patients with AMI, successfully revascularized with percutaneous coronary intervention, ejection fraction greater than or equal to 40%, and Killip class I-II. Patients were randomized into two groups: conventional therapy (n=55) and additional spironolactone of 25 mg/day with standard conventional therapy (n=55). Echocardiography was performed in the first 48-72 h of AMI and during 6 months of follow-up. Left atrial volume index and emptying fraction were obtained. The peak regional atrial contraction velocity, the time between the onset of p-wave on the monitor ECG and the onset, peak, and the end (TE) of the atrial contraction wave on the tissue Doppler technique curve were measured.The left atrial volume index and left atrium (LA) dimensions did not significantly change in either group. In the spironolactone group, left atrial emptying fraction increased compared with both baseline value (from 53.0 ± 0.16 to 57.0 ± 0.13 P=0.011) and conventional therapy group (from 50.0 ± 0.17 to 47.0 ± 0.16, P=0.013). The atrial contraction velocity did not change but the LA-TE, interatrial septum-TE, and right atrium-TE were prolonged in the conventional therapy group.Additional spironolactone therapy provided a little benefit on LA remodeling and atrial electromechanic properties in patients with AMI and preserved LV functions.

Background The prevalence of smoking is high in Turkey. However, there are no data available evaluating the differences between smokers and nonsmokers according to their sex in patients with acute myocardial infarction (AMI) in Turkey. Hypothesis The aim of the study was to determine the prevalence of smoking and its relationship to age, localization, and extension of coronary heart disease (CHD), and other risk factors in Turkish men and women with first AMI. Methods This study included, 1502 patients with first AMI from 3 different cities in Turkey. The baseline characteristics and traditional risk factors for CHD, Coronary angiographic results, and in-hospital outcome were recorded. Results The proportion of male smokers was significantly higher than that of women (68% vs 18%, P < 0.001). Smokers were younger by almost a decade than nonsmokers (P < 0.001). Male nonsmokers were younger than females; however, the mean age of first AMI was similar in male and female smokers. In both genders, prevalence of hypertension and diabetes mellitus was significantly lower in smokers than in nonsmokers (P < 0.001). Smokers had less multivessel disease and less comorbidity as compared to nonsmokers. Although the in-hospital mortality rate was lower in smokers, smoking status was not an independent predictor of mortality. Conclusions Smoking, by decreasing the age of first AMI in women, offsets the age difference in first AMI between men and women. The mean age of first AMI is lower in Turkey than most European countries due to a high percentage of smoking. Copyright © 2010 Wiley Periodicals, Inc.

Background: Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives. Methods: We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24-hour ambulatory BP < 130/80 mmHg. Results: In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =−0.27, P = 0.027; coefficient =−0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively). Conclusions: Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

The aim of this study is to show the artificial neural network (ANN) on determination of coronary artery disease existence and localization of lesion based upon exercise stress testing (EST) data. EST and coronary angiography were performed on 330 patients. The data studied acquiring 27 verifying features was normalized employing z-score method. To select training and test data, 10-fold cross-validation methods were involved and multi-layered perceptron neural network was employed for the classification. The interpretation of EST using ANN proved 91%, 73% and 65% diagnostic accuracy for the left main coronary (LMCA), left anterior descending and left circumflex coronary arteries, respectively. Besides, 69% for the right coronary artery is also predicted. For the LMCA, a 94% negative predictive value (NPV) was obtained. This high percentage of NPV encourages the elimination of LMCA lesions. Some knowledge can also be obtained about lesion localization, besides diagnosing of coronary artery disease by the assessment of EST via ANN.

This study was planned to investigate the normal reference values of myocardial performance index (MPI) obtained by tissue Doppler echocardiography (TDE) and the agreement between MPI measured by TDE and conventional MPI measured by pulsed-wave Doppler (PWD) in healthy subjects and patients with heart failure (HF). Two hundred and three patients with HF and 190 healthy subjects were enrolled in this study. Isovolumic contraction and relaxation time (ICT and IRT) and ejection time (ET) were measured from mitral inflow and left ventricular (LV) outflow. Tissue Doppler echocardiography recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus and same time intervals were measured. Myocardial performance index was calculated. The functional capacity of the patients with HF was determined according to New York Heart Association classification. TDE-MPI values were higher than conventional PWD-MPI values in both groups (53% ± 8% vs 48% ± 11%, P < 0.0001 in the healthy subjects; 84% ± 21% vs 72% ± 19%, P

WOS: 000265570300019, PubMed: 19293531, Background: To determine the individual effect of abnormalities in blood pressure (BP) circadian rhythm (non-dipping status (NDS), increased morning BP (MBP) or increased MBP surge (MBPS)) on target organ damage (TOD) and which of these is more closely related to TOD in normotensives. Methods and Results: The 24-h ambulatory BP monitoring (ABPM) and echocardiography were performed and urinary albumin excretion (UAE) was measured in 47 dipper (28 women, mean age 45.8 +/- 9.3) and 32 non-dipper (25 women, mean age 49.1 +/- 8.3 years) normotensive subjects. The left ventricular mass index (LVMI) was higher in non-dipper group (103.8 +/- 24.1 vs 91.6 +/- 23.5 g/m(2), 12, P=0.03). UAE in non-dipper group was higher, but the difference between the two was not statistically significant (18.9 [10.3, 28.9] vs 14.1 [7.5, 23.8], P=0.11). In multivariate analysis, both LVMI and UAE were affected by NDS and MBP independent of other confounding variables (for LVMI; Coefficient=0.27, P=0.01 and Coeffcient=0.37, P=0.001, respectively, and for UAE; Coefficient=0.27, P=0.02 and Coefficient =0.28, P=0.01, respectively). Conclusions: It may be Postulated that increased night and MBP are the factors that cause TOD, and it seems reasonable to attempt to restore normal diurnal rhythm of the BP even in normotensive Subjects. (Circ J 2009; 73: 899-904)

Exercise induced ST elevation, especially in anterior derivations, does localize the ischemic region. We describe a patient who presented with exercise induced ST elevation in both anterior and inferior leads without prior myocardial infarction. Coronary angiography showed a "wrap around LAD" with significant proximal lesion.

BACKGROUND The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M-mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. METHODS Seventy-two patients with T2DM (mean age 49.1 +/- 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 +/- 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M-mode flow propagation velocity (V(E)). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA(1C) level were determined. The association of FBG, PPG and HbA(1C) with the echocardiographic parameters was investigated. RESULTS It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA(1C) was found to be related to diastolic parameters such as E/A, Em/Am, V(E) and E/V(E) (beta=-0.314, P = < 0.05; beta=-0.230, P < 0.05; beta=-0.602, P < 0.001, beta= 0.387, P < 0.005, respectively). In addition to HbA(1C), LV, diastolic functions were also correlated with age and diabetes duration. CONCLUSION Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA(1C) levels may affect diastolic parameters.

A 72-year-old female patient with respiratory distress and chest pain was referred for echocardiography after which a severe aortic stenosis was diagnosed. From clinical perspective an AVR would have carried too much risk in this case, therefore TAVI with transapical approach via left anterior thoracotomy was the treatment of choice. In this case report, we describe our experience with this new procedure in our country.

Background:The purpose of this study was to examine the effects of exercise on maximum QTc interval (QTcmax) and QTc dispersion (QTcd) in diabetic patients without clinically evident heart disease. Methods: Seventy-six diabetic patients who had no coronary artery disease or hypertension (group I; mean age 48 ± 9 years old) and 40 healthy volunteers (group II; mean age 46 ± 13 years old) were enrolled in the study. Cases with clinically evident heart disease were excluded from the study. Resting 12-lead electrocardiogram (ECG) and maximal treadmill exercise test (according to Bruce protocol) were performed in all cases. The QTcmax interval was determined at rest (RQTcmax) and during peak exercise (PQTcmax). Also, the QTcd was measured at rest (RQTcd) and during peak exercise (PQTcd). Autonomic neuropathy was assessed by measuring the heart rate variability (HRV). Results: There was no significant difference between clinical characteristics of two groups. In group I, HRV parameters were significantly lower than group II. RQTcd, PQTcd, RQTcmax, and PQTcmax were significantly longer in group I (56 ± 16 vs 34 ± 11; P 0.05), and no significant difference was present between RQTcd and PQTcd (56 ± 16 vs 62 ± 22; P > 0.05, respectively). Conclusion: Exercise does not affect QTcd in patients with diabetes mellitus and without clinically evident heart disease.

Objectives This study was planned in order to investigate the effect of left bundle branch block (LBBB) on myocardial velocities obtained by tissue Doppler echocardiography (TDE) and myocardial performance index (MPI). Methods Subjects with LBBB (n = 61) and age-matched healthy subjects (n = 60) were enrolled in the study. Left ventricular (LV) ejection fraction (EF), mitral inflow velocities (E-wave and A-wave), isovolumetric contraction and relaxation time (ICT and IRT), ejection time (ET), and flow propagation velocity (Vp) were measured by conventional echocardiography. Systolic velocity (Sm), early and late diastolic velocities (Em and Am) and time intervals were measured by TDE. MPI was calculated by the formula (ICT + IRT)/ET. Results LVEF and mitral E/A ratio were similar in both groups. Vp was lower in the LBBB group than in the control group, whereas the E/Em and the E/Vp ratio was higher. LV Sm and Em/Am ratio were lower in LBBB group. Right ventricular Sm and Em/Am ratio were similar in both groups. LV mean and RV MPI were significantly increased in LBBB group. Conclusion These findings obtained by TDE show that isolated LBBB impairs the ventricular functions. Both of the LV and RV dysfunctions shown by the new parameters may contribute to increased morbidity and mortality in cases with isolated LBBB.

Objective: Asymptomatic patients with chronic aortic regurgitation (AR) have an excellent prognosis in the presence of preserved systolic function. It is a challenge to recognize patients with subclinical myocardial dysfunction in AR. Conventional parameters still have many drawbacks in predicting early left ventricular (LV) dysfunction. Pulsed-wave tissue Doppler imaging (PW-TDI) is a useful noninvasive technique for evaluating global and regional LV systolic function. In this study, we aimed to assess clinical usefulness of TDI in predicting early disturbance of myocardial contractility in asymptomatic patients with significant AR and preserved left ventricular systolic function. Methods and the Results: Echocardiograms were obtained in 32 AR patients and 33 healthy subjects. In addition to conventional parameters, regional myocardial velocities, isovolumetric contraction time (mICT), isovolumetric relaxation time (mIRT), and ejection time (mET) of left ventricle were obtained by TDI and modified LV myocardial performance index (MPI) was calculated. In AR, peak systolic velocity (Sm) of septal and anterior mitral annulus, and mean Sm was significantly lower, and LVMPI was significantly higher compared to control group. Conclusion: The data obtained by TDI show that LV MPI is lengthened, and systolic myocardial velocities are shortened in patients having chronic AR with normal LV systolic function according to conventional echocardiographic parameters. This suggests that LV long-axis contraction and global LV performance are preciously and noticeably decreased in patients with moderate-to-severe chronic AR despite normal LV ejection fraction.

WOS: 000248208200006, PubMed: 17674379, Doppler-derived myocardial performance index (MPI) has been described as a noninvasive measurement of LV function. Our aim was to investigate the effect of hemodialysis related volume reduction and heart rate changes on the Doppler-derived LV MPI, and Doppler tissue imaging (DTI) derived left and right ventricular MPI. Method: The study group comprised 32 consecutive patients (mean age: 43 18 yrs) undergoing hemodialysis. Patients underwent echocardiography before and immediately after hemodialysis session. Left and right ventricular MPI derived from conventional pulsed-wave Doppler and DTI was calculated. The difference in MPI, heart rate and body weight was calculated before and after hemodialysis. Results: Doppler-derived LV MPI, and right ventricular MPI obtained by DTI were increased (p = 0.05) but the LV MPI obtained by DTI was unchanged after hemodialysis. There is a significant positive correlation between the Doppler-derived LV MPI difference and volume reduction (r = 0.38, p = 0.032). The heart rate difference was correlated with Doppler-derived LV MPI difference, and DTI derived right ventricular MPI difference (r = 0.38, p = 0.034; r = 0.48, p = 0.006, respectively). Whereas, DTI derived LV MPI difference was not correlated with heart rate difference. By the multivariate analysis, there was no correlation between Doppler-derived LV MPI difference with heart rate difference, and volume reduction. Right ventricular MPI difference correlated with heart rate difference (r = 0.41, p = 0.021) but not with volume reduction. Doppler-derived MPI is partially influenced by preload and heart rate changes. However, DTI derived LV MPI is not influenced by preload and heart rate changes.

Coronary anomalies are relatively common but rarely associated with syncope, myocardial ischemia, and sudden cardiac death. An anomalous right coronery artery from the left sinus of valsalva is now recognized as an important causative factor in sudden death and myocardial infarction and syncope.This case report presents an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva with syncope and will be focused on the diagnostic variation and management., Koroner anomaliler göreceli olarak yaygın olmasına rağmen nadiren senkop, miyokardiyal iskemi ve ani kardiak ölümle ilişkilidir. Sol sinüs valsalvadan köken alan sağ koroner arter anomalisi ani ölüm,miyokardiyal iskemi ve senkobun en önemli sebebleri arasındadır.Bu vaka takdiminde sol sinüs valsalvadan köken alan sağ koroner arter anomalisinin tanısal çeşitliliği ve hasta yönetimini ele alınmaktadır

The neutrophil to lymphocyte ratio (NLR) predicts cardiovascular events. The aim of this study was to determine whether NLR improved the positive predictive value (PPV) of dobutamine stress echocardiography (DSE) in patients with stable coronary artery disease (CAD). We conducted a retrospective review of laboratory and DSE data from the medical records of 1,012 patients who were divided into two groups according to the presence of ischemia and further subdivided into three groups according to the extent of ischemia (nonischemic segments, 1-3 ischemic segments, or > 3 ischemic segments). NLRs were compared among these groups. NLRs increased in patients with ischemia and correlated with the number of ischemic segments (P < 0.001). The optimal cutoff value of NLR determined using receiver operating characteristic analysis was > 2.04, and the diagnostic value of NLR for discriminating patients with ≥ 50% coronary stenosis in at least one of the coronary arteries from those without significant CAD was high [area under the curve (AUC) = 0.671, standard error = 0.052, P < 0.001, 95% confidence interval (CI) = 0.569-0.773)]. An NLR cutoff value of > 2.04 predicted CAD presence with significant stenosis (62.10% sensitivity and 64.10% specificity). PPV of DSE for a significant coronary artery lesion identified using coronary angiography was 73.8% (95% CI = 75.1-88.5, P < 0.001, AUC = 0.818). On including a cut-off value of > 2.04 for NLR in this multivariable predictive model, the AUC value slightly increased to 0.905 (95% CI = 85.4-95.6) and PPV of DSE increased from 73.8% to 92.6%. NLR improved PPV of DSE for patients with stable CAD.

Background The aim of this study was to examine the Tpeak-Tend (Tpe/corrected Tpe) interval, which is an indicator of transmural myocardial repolarization, measured non-invasively via electrocardiogram in patients with acute pulmonary embolism (PE), and to investigate the relationship with 30-day mortality and morbidity. Methods The study included 272 patients diagnosed with acute PE, comprising 154 females and 118 males, with a mean age of 63.1 ± 16.8 years. Tpe/cTpe intervals were calculated from the electrocardiograms with a computer program after using a ruler or vernier caliper manual measuring tool to obtain highly sensitive measurements. The relationship between the electrocardiogram values and 30-days mortality and morbidity were measured. Results The study group was divided into three groups according to cTpe intervals: Group 1, < 113 ms; Group 2, 113–133 ms; and Group 3, > 133 ms. White blood cell count and troponin T levels, corrected QT intervals with QRS complex durations, percentage of right ventricle dilatation with right/left-ventricular ratio, 30-day death, and combinations of these values were seen at a higher rate in Group 3 patients compared to the other groups. Kaplan–Meier analysis showed that the cTpe interval measured at > 126 ms could be used as a cut-off value in the prediction of mortality and morbidity. The cTpe cut-off values of 126 ms had sensivity, specificity, negative predictive value, and positive predictive value of 80.56 %, 59.32 %, 95.2 %, and 23.2 %, respectively. Conclusions cTpe interval could be a useful method in early risk stratification in patients with acute PE.

Studies have shown disparate results in relation to the role of plasma concentrations of inflammation markers such as fibrinogen, cytokines, and cell adhesion molecules in acute coronary syndromes. The differentiation of primary versus secondary alterations of these markers in response to acute coronary syndromes is not clear. The aim of this study was to investigate the effect of soluble cell adhesion molecules and some inflammatory markers on coronary plaque instability. The prospective study consisted of 15 patients with stable angina pectoris (SAP), 16 with unstable angina pectoris (UAP), and 16 who had undergone percutaneous transluminal coronary angioplasty (PTCA). Blood samples were obtained from the SAP group on admission, from the UAP group at the early stage of pain onset within 6 h of pain, and again after 12 h of pain. Samples from the PTCA group were collected before, 2, 14 h after the procedure. Soluble vascular cell adhesion molecule-1 (VCAM-1), endothelial selectin, interleukin-1 beta (IL-1 beta) and interleukin-2 (IL-2), and C-reactive protein (CRP) were analyzed by enzyme-linked immunosorbent assay. CRP serum levels gradually increased although IL-2 gradually decreased in patients with UAP and PTCA. In addition, VCAM-1 levels were sharply decreased after the PTCA procedure. However, this value returned back to the preprocedure levels 14 h after PTCA. Both CRP and IL-2 are directly involved in the triggering mechanisms of acute coronary events.

Background: Doppler pulmonary venous flow velocities (PVFV) pattern are useful parameters in assessing the left ventricular diastolic functions. Both mitral stenosis (MS) and aortic stenosis (AS) lead to diastolic dysfunction. We compared PVFV and left ventricular diastolic and ejection time (ET) in patients with moderate MS and AS. Methods: Forty-three patients with moderate MS (group 1), 65 patients with moderate AS (group 2), and 33 healthy subjects as controls (group 3) were included in this study. After obtaining standard measurements echocardiographically, diastolic period (DP), ET, the ratio of the DP to the ET (DP/ET), isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), peak systolic flow velocity (PS), peak antegrade diastolic flow velocity (PD), peak reversal flow velocity at atrial contraction (PRA), the ratio of the peak systolic to the diastolic flow velocity (PS/PD), deceleration time of the antegrade diastolic flow (PDDT), and pressure half time of the peak antegrade diastolic flow velocity (PDPHT) were measured. Mitral valve area (MVA), aortic valve area (AVA), systolic pulmonary artery pressure (PAP), peak and mean gradients were calculated with standard formulas. Results: In univariate analysis, MVA was correlated with PDPHT and PDDT (r = −0.41; p < 0.01, r = −0.36; p < 0.05, respectively), also it was correlated with DP/ET (r = −0.57; p < 0.001). Mitral peak and mean diastolic gradient were correlated with PS/PD (r = −0.43; p < 0.01, r = −0.36; p < 0.05, respectively) and DP/ET (r = 0.51; p < 0.01, r = 0.46; p < 0.01, respectively). AVA was only correlated with DP/ET (r = 0.38; p < 0.05). Aortic peak and mean systolic gradient were correlated with PS/PD (r = −0.29; p < 0.05, r = −0.27; p < 0.05, respectively) and DP/ET (r = −0.38; p < 0.01, r = −0.40; p < 0.01, respectively). In the same analysis, PAP in patients in group 1 and 2 was correlated with PS/PD (r = −0.42; p < 0.01 and r = −0.40; p < 0.01, respectively) and also it was correlated with PD (r = 0.37; p < 0.05 and r = 0.27; p < 0.05, respectively) in both groups. Conclusion: Moderate MS and AS similarly affect the PVFV, and PS/PD correlates with hemodynamics similarly both in MS and AS. Nevertheless, PDDT and PDPHT correlate with solely MVA. IRT higher in AS than MS, though DP/ET and ICT higher in MS than AS, and DP/ET relates with the severity of both MS and AS.

Primer aldosteronizm hipertansiyon, hipopotasemi, yüksek plazma aldosteron seviyesi ve düşük plazma renin aktivitesiyle kara- kterize bir sendromdur. Bizim takdim ettiğimiz hasta proksimal kas güçsüzlüğü ve yorgunluk şikayetleriyle nöroloji kliniğine başvuran 56 yaşında bir erkek hastaydı. Kontrolsüz kan basıncı nedeniyle anti-hipertansif tedavi planlanması amacıyla kardiyoloji konsultasyonu istenmiş. Ciddi hipokalemiye bağlı (K:1.04) uzamış QT intervali ve dev U dalgaları olması nedeniyle hasta kardiy- oloji kliniğine aritmi riskleri açısından devralındı. Primer hiperaldosteronizm teşhisi konulduktan sonra tedavi başlandı ve tedavi boyunca hastada ciddi poliüri gelişti(19 L/gün)., Primary aldosteronism is a syndrome that is characterized with hypertension, hypopotasemia, high level of plasma aldosterone, and low plasma renin activity. The case we present is a 56-year-old male who referred to our neurology clinic with proximal muscle weakness and fatigue. Because of uncontrolled blood pressure, a cardiology consultation was performed for the planning of anti- hypertensive treatment. As prolonged QT intervals and giant U waves due to serious hypokalemia (K:1,04), cardiology clinic took over the patient for risks of arrhythmia. After primary hyperaldosteronism diagnosis was established, the treatment was initiated and severe polyuria developed during the treatment (19L/day).

Background: Pure mitral stenosis (MS) affects left-ventricular performance as a result of myocardial and functional factors. We planned this study to evaluate the effect of MS on right- and left-ventricular functions using Doppler tissue imaging (DTI). Methods: A total of 46 patients with an established diagnosis of MS (mean age: 41 ± 11 years), and 40 age-matched healthy individuals (mean age: 40 ± 9 years) were included in this study. Echocardiography equipped with DTI function was performed on each participant. The mitral valve area was measured. Myocardial velocities were recorded at 4 different sites (septum, lateral, anterior, and inferior) of the left ventricle, and the right-ventricular free wall annulus by DTI. The positive systolic velocity when the mitral and tricuspid ring moved toward the cardiac apex, and 2 negative diastolic velocities when the mitral annulus moved toward the base away from the apex (1 during the early phase of diastole and another in the late phase of diastole [A m ]) were measured. The early diastolic velocity/A m ratio was calculated for each wall. The mean of systolic and diastolic myocardial velocities of the left ventricle was calculated. Patients with pure MS were compared with healthy participants, and the relationship of DTI variables with mitral valve area was evaluated. Results: The myocardial velocities of the left ventricle indicating left-ventricular function were found to be significantly lower in patients with pure MS. Right-ventricular annulus velocities, on the other hand, were similar in both groups. A significant positive correlation could be established between mitral valve area and mean positive systolic velocity, A m of the left ventricle, and right-ventricular A m ( r = 0.50, P r = 0.48, P =.001; r = 0.45, P =.002, respectively), whereas a significant negative correlation ( r = −0.42, P =.004) was established for right-ventricular early diastolic velocity/A m ratio. Conclusion: This first study where pure MS was evaluated by DTI shows that MS affects left-ventricular performance on long axis. The results indicate that the decrease in left-ventricular performance is caused by both functional and myocardial factors. (J Am Soc Echocardiogr 2002;15:1472-8.)

The authors evaluated the effects of beta blockers (metoprolol) and calcium channel blockers (diltiazem) in patients having mild to moderate mitral stenosis (MS) with sinus rhythm. Eighty patients with a complaint of dyspnea with diagnosed MS were included in this study. Patients were randomized into metoprolol and diltiazem groups. The first group received oral diltiazem treatment for 3 months following an IV dose of 25 mg diltiazem. The second group received oral metoprolol for 3 months following an IV dose of 5 mg metoprolol. All patients performed a treadmill exercise test at the beginning of and after 3 months of treatment. Transthoracic echocardiographic studies were also performed following the IV drug administration and after 3 months of treatment. In addition, oxygen uptakes of patients were measured before and after the stress and after 3 months of treatment. Decreases in peak gradient (PG) and mean transmitral gradient (MG) were observed in the metoprolol group after IV and oral metoprolol treatment. A prolongation of exercise time in treadmill exercise test (TET) and a decrease in the maximum heart rate after oral metoprolol treatment were noted. Eighteen patients in the metoprolol group had benefited symptomatically from this treatment and complaints of dyspnea were alleviated, whereas no symptomatic relief was seen in the diltiazem group. No significant prolongation was observed in effort times (p>0.05) of the diltiazem group. Transmitral gradients measured via echocardiographic examination did not change (p>0.05). With respect to oxygen uptake rates, a statistically significant decrease was determined in the metoprolol group, whereas no difference was found in diltiazem group. The authors conclude that metoprolol may be useful in patients with MS and can provide symptomatic relief. They did not observe any beneficial effect of diltiazem in these patients.

The previous studies relating to the effect of the Valsalva maneuver on P wave do not provide detailed information. In those studies, the parameters related to P wave duration during the release phase of the Valsalva maneuver were evaluated. The authors evaluated P wave amplitude as well as P wave duration during the strain phase of the Valsalva maneuver. Thirty- seven normal subjects and 36 patients with paroxysmal atrial fibrillation (PAF) were included in the study. Twelve-lead surface electrocardiography (ECG) was obtained from all the patients before and during the strain phase of the Valsalva maneuver. The authors evaluated the para meters related to both P wave duration and P wave amplitude. The highest P wave voltage was expressed as the P wave amplitude maximum (P amp max), the lowest P wave voltage as the P wave amplitude minimum (P amp min), and the P wave amplitude dispersion (P amp dispersion) as "the P amp max — the P amp min." Also, the maximum P wave duration was expressed as the P maximum (P max), the minimum P wave duration as the P minimum (P min), and the P wave dispersion as "the maximum P wave duration (P max) — the minimum P wave duration (P min)." All these parameters were measured before and during the strain phase of the Valsalva maneuver. P max, P dispersion, P amp max, and P amp dispersion were higher in patients with PAF compared to those of normal subjects before the Valsalva maneuver. In normal subjects, P max, P wave dispersion, P amp max, and P amp dispersion values were significantly higher in the strain phase of the Valsalva maneuver than before (p

Subacute left ventricular free wall rupture is a rare complication in acute myocardial infarction. With the increasing use of thrombolytic agents and glycoprotein IIb/IIIa inhibitors, this complication has been increasing recently. We report a case of subacute cardiac rupture with frank pericardial effusion receiving thrombolytic and glycoprotein IIb/IIIa inhibitor therapies.

Origination of the right coronary artery from the distal left circumflex artery is a rare anomaly. A 63-year-old woman was admitted with subacute anteroseptal myocardial infarction. Electrocardiography showed a QS pattern in V1-V3 precordial leads without ST elevation. Cardiac enzyme levels were elevated (CK-MB 186 ng/ml, troponin I 27.1 ng/ml). Echocardiography showed hypokinesia of the anterior and lateral walls without valvular pathology. Coronary angiography revealed origination of the right coronary artery from the circumflex artery. The right coronary artery had a normal flow pattern and there were atherosclerotic plaques in the circumflex artery without a significant stenosis. Distal to the first diagonal branch of the left anterior descending artery, a 95% stenotic lesion was detected, which was treated with balloon dilatation followed by implantation of a bare metal stent. The patient was discharged with near-complete patency and without any complication.

Background The aim of this study was to evaluate the reliability of peak mitral inflow (E-wave) velocity, which was thought to be easier and more practical than qualitative and quantitative methods used to grade mitral regurgitation (MR) in patients both with normal and low left ventricular (LV) ejection fraction (EF). It is known that peak E-wave velocity increases in MR. But correlation of this increase with regurgitant fraction (RF), its usefulness in grading MR, and the effect of EF on peak E-wave velocity have not been studied in detail. Methods We prospectively examined 135 consecutive patients with varying grades of MR with echocardiography. MR was evaluated both qualitatively and quantitatively, and concordance of these 2 methods was determined. Peak E-wave velocity, A-wave velocity, and E-wave deceleration time were measured and the E/A ratio was calculated. LV isovolumetric relaxation and contraction times were measured. Different MR groups classified by RF were compared with each other. Results Concordance of quantitative and qualitative evaluation was low in patients with low EF (κ 0.37 vs 0.65). Peak E-wave velocity and E/A ratio showed significant differences between MR groups. Peak E-wave velocity correlated with the RF and EF ( r = 0.47, r = 0.33, respectively, P 1.2 m/s suggesting severe MR were found to be different in patients with normal and low EF (96% vs 66%, 78% vs 83%, 97% vs 78%, respectively). E-wave deceleration, LV isovolumetric relaxation, and contraction time did not show a correlation with RF. Conclusion Peak E-wave velocity is a screening method that could be used in common for determining severity of MR semiquantitatively, especially in patients with normal EF. (Am Heart J 2001;142:1065-71.)

Complications related to percutaneous placement of intra-aortic balloon pump counterpulsation are still high despite major refinements in catheter design and techniques. One hundred and forty-eight patients in whom intra-aortic balloon pumping was inserted were classified into two groups on the basis of the insertion technique. Group I included 103 patients in whom the conventional percutaneous insertion was used. A sheathless insertion technique was used in group II (n = 45). The overall complication rate was 16.6% (25 of 150), in which lower limb ischaemia was the most common complication. The limb ischaemia was noted in 12 patients (11.5%) in group I and 4 patients (8.9%) in group II (statistically not significant). Peripheral vascular disease, diabetes mellitus and female gender were found to be significant predictors of limb ischaemia (p = 0.01, p = 0.02 and p = 0.03, respectively). In conclusion, sheathless insertion of intra-aortic balloon pump catheters does not reduce the incidence of limb ischaemia.

Uhl's anomaly is a rare congenital hypoplasia of the right ventricular (RV) myocardium. It can be seen together with some other congenital anomalies. Here we first report a 16-year-old male patient with Uhl's anomaly which appears with cardiac tamponade.

Congenital ventricular diverticulum is defined as a protrusion of the free wall of the ventricle, including endocardium, myocardium and pericardium. They have been classified in fibrous and muscular types. Congenital ventricular diverticulum may be asymptomatic or may be present with various clinical symptoms. Diverticulum is commonly seen in childhood, and fibrous type being the most common type. Muscular type is very rare seen in adults. We report here, a case with muscular type asymptomatic congenital left ventricular diverticulum in a 65 year-old female.

In this report, a novel management to the problem of a fractured balloon catheter which is a very rarely seen complication and has not yet been reported in the nature as in our case during percutaneous transluminal coronary interventions is presented. We inserted a second balloon catheter to the space between the previous fractured balloon and the wall of right coronary artery, and then by inflating the second balloon catheter at low pressure, the guide-wire of fractured balloon catheter and the second sound balloon catheter gently and cautiously removed together into the guiding catheter. Subsequently, the whole system was taken out of the body without complication.

Although elevated red blood cell distribution width (RDW) is associated with adverse outcomes in patients with cardiovascular disease, its role in demonstrating the presence and extent of myocardial ischemia for coronary artery disease is not known. The purpose of this study is to investigate the relationship between RDW and myocardial ischemia by using dobutamine stress echocardiography (DSE).A total of 917 patients were included in this prospective study. A complete blood analysis was performed for RDW before DSE. According to DSE results, patients were divided into two groups: DSE negative and DSE positive. According to the number of ischemic segments in DSE, patients were divided into three groups: no-ischemic segment, 1-3 ischemic segments, and ≥4 ischemic segments. In addition, coronary angiography results of DSE-positive groups were assessed in respect of RDW.The RDW of the DSE-positive group (n=277) was higher than for the DSE-negative group (n=640) (13.5±1.5 vs. 12.7±1.3%, P0.001, respectively). Elevated RDW values were also related to higher number of ischemic segments (no-ischemic segment group: 12.7±1.3, 1-3 ischemic segments group: 13.2±1.5, and ≥4 ischemic segments group: 14.2±1.3, P0.001). A receiver operating curve analysis showed a cut-off value of RDW greater than 13.5% for predicting myocardial ischemia (sensitivity: 57.0%, specificity: 77.8%, positive predictive value: 52.7%, negative predictive value: 80.7%). In addition, positive predictive value of DSE was increased from 82.4 to 94.2% for detecting coronary artery disease by coronary angiography, when RDW (13.5%) was used.RDW is related to the presence and extent of myocardial ischemia in DSE. A high RDW increases the diagnostic accuracy of DSE.

The mortality of right heart thrombi (RHT) associated with pulmonary embolism (PE) is increased about three to four times. The most devastating scenario is fragmentation of RHT and occurrence of recurrent PE. The reports regarding the management of RHT complicated with PE are very scarce in the current literature. Therefore, we report a single-center experience in this paper.From January 2006 to December 2011, data of all patients diagnosed with acute PE were analyzed retrospectively. Of the 312 acute PE cases confirmed with computed tomography, total 35 patients who were diagnosed with concomitant RHT (prevalence of 11%) by echocardiography were recruited. After excluding of six patients with metastatic malignancy a total 29 patients were accepted eligible for the analysis. In addition, catheter -induced thrombus (type B) were not included to the study. The difference between categorical variables was analyzed with Chi-square test and continuous variables were analyzed with Mann-Whitney U test. A p value of0.05 was considered statistically significant.Overall mortality was high (34%) in study population: among undergoing surgery-100%, therapy with thrombolytics -18%, and heparin -27%. Troponin levels were found significantly higher in died patients than that in survived patients (p=0.03). There was no significant difference regarding to clinical and echocardiographic characteristics of patients received heparin versus thrombolytic except for shock index (p=0.02). In addition, patients treated with heparin had increased duration of hospitalization compared to subjects treated with thrombolytic (median: 8 vs 3 days p0.01).Despite of the low incidence of RHT, a mortal course is still an important problem during PE. The decision on treatment modality should be performed based on the hemodynamic parameters, laboratory findings, and bleeding risk of the patients.AMAÇ: Pulmoner emboli (PE) ile ilişkili sağ kalp trombüslerinin mortalitesi 3-4 kat artmaktadır. En korkulan senaryo ise sağ kalp trombüslerinin parçalanması sonucunda rekürren pulmoner emboli gelişmesidir. Pulmoner embolilere eşlik eden sağ kalp trombüsü vakalarının tedavisi zordur ve bu konu ile ilgili literatürde yeterli veri bulunmamaktadır. YÖNTEMLER: Ocak 2006 ila Aralık 2011 tarihleri arasında akut pulmoner emboli tanısı almış 312 hastanın verileri retrospektif olarak incelendi. Bilgisayarlı tomografi ile tanı almış 312 akut PE hastalarından ekokardiyografide sağ kalp trombüsü bulunan 35 hasta çalışmaya alındı. Metastatik malignansi bulunan 6 hasta çalışmadan dışlandı. Yirmi dokuz hasta değerlendirilme için uygun bulundu. Hastaların ekokardiyografik raporları da incelendi. Ayrıca katetere bağlı gelişen trombüs (tip B) vakaları da çalışmaya dahil edilmedi. Kategorik değişkenlerin karşılaştırılmasında Ki-kare ve non-parametrik sürekli değişkenlerin karşılaştırılmasında ise Mann-Whitney U testleri kullanıldı. P değerinin 0,05’in altında olması istatistiksel olarak anlamlı kabul edildi.Hastaların mortalite oranı yüksek bulundu (%34): cerrahi mortalite %100, trombolitik alanlardaki mortalite %18 ve heparin alanlarda mortalite %27 bulundu. Ölen hastalardaki troponin düzeyleri hayatta kalan hastalara göre anlamlı olarak yüksek bulundu (p=0,03). Heparin alanlarla trombolitik tedavi uygulanan gruplar arasında klinik ve ekokardiyografik olarak anlamlı fark saptanmadı. Fark sadece şok indeksinde saptandı (p=0,02). Ek olarak heparin alan hastaların yatış süresi trombolitik alanlara göre anlamlı olarak uzun bulundu (ortanca olarak 8 güne karşın 3 gün, p0,01). SONUÇ: Akut pulmoner emboliye eşlik eden sağ kalp trombüsü vakalarının insidansının düşük olmasına rağmen mortalitelerinin yüksek seyretmesi halen önemli bir problem olarak kalmaktadır. Tedavi modalite seçiminde hastanın hemodinamik değerleri, laboratuvar parametreleri ve kanama riskleri esas alınarak karar verilmelidir.