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Background and Objectives Lymphocyte-to-monocyte ratio (LMR) has emerged as a new indirect marker of inflammation, which is associated with adverse outcomes in cardiovascular diseases. The aim of this study was to evaluate whether admission LMR is associated with contrast-induced nephropathy (CIN) in patients who underwent percutaneous coronary intervention for acute coronary syndrome (ACS). Methods A total of 873 patients were assessed. LMR was calculated via dividing lymphocyte count by monocyte count. Results LMR was significantly lower in the with-CIN group. ROC analysis showed that the LMR ratios Conclusion LMR is an easily accessible marker and could be used as a predictor of CIN in patients with ACS undergoing percutaneous coronary intervention.

Aims Attenuating exercise-induced elevated left atrial pressure with an atrial shunt device is under clinical investigation for treatment of symptomatic heart failure (HF). Methods and results PRELIEVE was a prospective, non-randomised, multicentre, first-in-man study in symptomatic HF patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction and pulmonary capillary wedge pressure (PCWP) >= 15 mmHg at rest or >= 25 mmHg during exercise. Here, we provide follow-up data up to 1 year after implantation of the Atrial Flow Regulator (AFR) device. The AFR was successfully implanted in 53 patients (HFrEF n = 24 and HFpEF n = 29). Two patients were not enrolled due to an unsuccessful transseptal puncture. There was one device embolisation into the left atrium, which required surgical removal. One patient experienced a serious procedure-related adverse event (post-procedural bleeding and syncope). All patients with sufficient echocardiography readout confirmed device patency with left-right shunt both at 3 (n = 47/51, 92%) and 12 (n = 45/49, 92%) months. At 3 months, rest PCWP decreased by 5 (-12, 0) mmHg (P = 0.0003, median Q1, Q3). No patient developed a stroke, worsening of right heart function or significant increase of pulmonary artery pressure. Six (6/53, 11%) patients were hospitalised for worsening of HF and three (3/53, 6%) patients died. We observed improvements in New York Heart Association functional class, 6-min walking distance and quality of life (Kansas City Cardiomyopathy Questionnaire) in certain patients. Conclusions Implantation of the AFR device in HF patients was feasible. No shunt occlusion, stroke or new right HF was observed during the 1-year follow-up, with clinical improvements in certain patients., Occlutech International AB, The study was supported by Occlutech International AB.

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.

Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis. However, the designs of the cylindrical balloons historically used for valvuloplasty have limitations, especially in patients who have large pulmonary annular diameters. The hourglass-shaped V8 Aortic Valvuloplasty Balloon may prove to be an effective alternative. The balloon has 2 large bulbous segments that are separated by a narrowed waist. The geometric shape is maintained throughout inflation, improving fixation and enabling broader leaflet opening. We present our first experience with the V8 balloon in 3 adults who had severe, symptomatic pulmonary valve stenosis. In addition to describing their cases, we detail our sizing technique for pulmonary valvuloplasty with the V8 balloon. Our successful results suggest that the V8 balloon is efficient and safe for balloon pulmonary valvuloplasty in adults with severe pulmonary valve stenosis.

Summary: Background: Many studies have been conducted about the existence of obesity paradox in cardiovascular diseases. But, there is limited data on elderly patients. The aim of this study is to explore the existence of the “obesity paradox” and effect of obesity in periprocedural outcomes in patients presenting with acute myocardial infarction (AMI). Methods: This study involved elderly patients (≥65 years) who admitted our clinic with AMI and treated for acute STEMI between April 2011 and November 2014. Patients were divided into two groups according to their body mass index (BMI [kg/m2]) and a BMI>30 kg/m2 was accepted as obese. We compared angiographic, electrocardiographic, echocardiographic data and in-hospital mortality between two groups. Results: A total of 127 patients were included in the study and obese (BMI>30 kg/m2) patients comprised 27.3% (47) of all AMI patients. Analysis of the acute coronary angiographic data revealed that the number of significant coronary lesions was higher in non-obese group (p:0.04). The last TIMI-3 rate was higher in the obese group (%91.5 vs %79.2, p:0.05), whilst corrected TIMI frame count was lower (26 ± 13 vs 32 ± 14, p:0.01). In multivariate analysis, the number of lesions was correlated with obesity (OR 0.47, 95%CI 0.37–0.99, p:0.04). Conclusion: In our study, obesity was associated with better coronary flow after percutaneous coronary intervention and the number of lesions was lower in obese patients compared to non-obese elderly patients treated for STEMI. Our results were consistent with the phenomenon of “the obesity paradox”. Keywords: elderly, obesity paradox, myocardial infarction

Zoghi, Mehdi/0000-0002-8156-2675, WOS: 000490322500006, PubMed: 31130524, Aims: Reducing elevated left atrial pressure with an atrial septum shunt device is a possible treatment option in symptomatic heart failure patients. This study aimed to investigate the safety and feasibility of the Atrial Flow Regulator (AFR) in heart failure patients. Methods and results: AFR-PRELIEVE is a prospective, non-randomised, open-label, multicentre study in patients with symptomatic heart failure NYHA Class III or IV and pulmonary capillary wedge pressure (PCWP) >= 15 mmHg at rest or >= 25 mmHg at exercise irrespective of left ventricular ejection fraction (EF >= 15%). Here we report on procedural and three-month follow-up data for a total of thirty-six enrolled patients. Sixteen (44.5%) patients with reduced EF (HFrEF: EF 15-39%) and twenty (55.5%) patients with preserved EF (HFpEF: EF >= 40%) were enrolled. Implantation success rate and device patency with left-right shunt was 100% (post procedure and at three months) in both patient groups, with one SADE in the HFpEF group which completely resolved. Three (3/36, 8.3%) patients were hospitalised for worsening of heart failure (two HFrEF patients, one HFpEF patient). Individual patients from both the HFrEF and HFpEF groups showed improvement in symptoms and surrogate parameters of heart failure (NYHA class, six-minute walking distance, Kansas City Cardiomyopathy Questionnaire, PCWP, NT-proBNP). Conclusions: Implantation of the AFR device in heart failure patients is feasible and safe; shunt patency at three months was confirmed in the study. the atrial shunt improved symptoms and surrogate parameters of heart failure in some but not all patients in both the HFpEF and HFrEF groups., Occlutech S.A., The study was funded by Occlutech S.A.

Various approaches such as antegrade trans-septal, retrograde transfemoral and transapical techniques have been used to close mitral paravalvular leak (PVL) in patients with an aortic prosthesis. During the implementation of these techniques, an arteriovenous guidewire loop is often created for device delivery. However, passing through a mechanical aortic valve may cause hemodynamic compromise and prolong the procedure. To date, no studies have evaluated antegrade mitral PVL closure without the use of an arteriovenous wire loop in patients with a mechanical aortic prosthesis. Herein is described a different mitral PVL closure technique by means of a trans-septal approach without construction of an arteriovenous guidewire loop in this type of patient.Four patients (two males, two females; mean age 57 ± 10 years; range: 46-67 years) with severe mitral PVL and a mechanical aortic prosthesis were referred for percutaneous closure of a mitral PVL. All patients underwent antegrade trans-septal mitral PVL closure without the creation of an arteriovenous wire loop. Data prospectively collected included assessments from preoperative and postoperative two- and three-dimensional transesophageal echocardiography (TEE).Preoperative TEE demonstrated severe mitral PVL in all four patients. All patients experienced a substantial reduction in symptoms associated with the marked reduction in PVL following repair. There were no procedural complications. The median procedural time was 113 min (range: 50-145 min) and median fluoroscopy time was 23 min (range: 17-25 min).An alternative, safe, effective and efficient mitral PVL closure approach in patients with a mechanical aortic prosthesis has been devised. This technique can prevent aortic valve dysfunction, reduce costs, and also decrease complication rates.

Background: We aimed to investigate the effects and dose dependency of aspirin on endothelial functions and prevalence of aspirin resistance in newly diagnosed hypertensive patients without previous drug therapy and development of cardiac complications. Hypothesis: Acetylsalicyclic acid improves endothelial function. Methods: Fifty-eight hypertensive patients and 61 healthy subjects in the control group were included in the study. Endothelial functions of the patient and control groups were evaluated with brachial artery examination. Patient and control groups were divided into 2 groups. A total of 100 mg and 300 mg of aspirin were given to the separate groups for 1 week. After 1 week, endothelial functions were reevaluated and aspirin resistance examined with a platelet function analyzer (PFA-100; Dade Behring, Marbourg, Germany). Results: Baseline flow-mediated dilatation (FMD) change percent in hypertensive patients was 9.8%, and it was significantly lower than in the control group (12%) (P < 0.001). Frequency of acetylsalicylic acid (ASA) resistance was 20% and 26% in control and hypertensive patient groups, respectively (P = not significant). ASA resistance was 28% and 24% in 100 mg and 300 mg in hypertensive patients, respectively (P = not significant). FMD change percent increased both in the control and hypertensive groups after ASA treatment from 12.4% to 13.3% and 9.8 % to 11.9 %, respectively. FMD percentage change was significantly increased in hypertensive patients irrespective of ASA resistance (P = 0.02, for ASA resistance [+]; P < 0.012, for ASA resistance [−]). Conclusions: Endothelial functions were impaired more in hypertensive patients compared to the control group. Endothelial functions were improved with all ASA doses in hypertensive patients irrespective of ASA resistance. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Background Thromboembolic risk in permanent atrial fibrillation (AF) is strongly associated with the underlying etiology, and inflammatory parameters may contribute. The present study aimed to investigate the relationship of hs-CRP and BNP levels with left and right atrial appendage (LAA and RAA) function, presence of spontaneous echo contrast (SEC) and thrombus. Material/methods Eighty-four permanent AF patients with different etiologies (20 mitral stenosis, 44 hypertension and 20 hyperthyroidism) and 23 patients with sinus rhythm were included. LAA and RAA flow velocities were measured by pulsed-wave Doppler and wall motion velocities with tissue Doppler imaging (TDI) in transesophageal echocardiography. Results Hs-CRP and BNP levels significantly differed among the 3 AF groups: levels were highest in mitral stenosis patients (8.6 ± 5.3 mg/L and 98.0 ± 125.7 pg/mL, respectively), the lowest hs-CRP was in hyperthyroidism patients (4.3 ± 3.8 mg/L), and the lowest BNP was in hypertensive patients (64.8 ± 44.3 pg/mL). There were also significant differences between the AF group and controls regarding hs-CRP and BNP levels. In the correlation analysis, BNP level was not significantly correlated with LAA and RAA functions, whereas hs-CRP level was significantly correlated with some LAA and RAA functions. On the other hand, hs-CRP level was significantly related to the presence of mild-moderate SEC and thrombi, mainly in mitral stenosis patients. Moreover, hs-CRP was the most important determinant of RAA thrombus formation, followed by RAA ejection fraction. In contrast, no positive or negative correlation was found between BNP levels and RAA and LAA thrombi. Conclusions Higher hs-CRP levels in AF patients may be a predictor for the presence of SEC and thrombi in the atria.

Background: Cardiac resynchronization therapy (CRT) is recommended for patients with advanced chronic heart failure. The presence of left ventricular (LV) dyssynchrony before CRT is an important predictor of response to the therapy. We aimed to investigate time course of LV dyssynchrony after CRT and the relationship between LV dyssynchrony improvement and reverse remodeling (RR). Hypothesis: The relationship between the improvement of LV dyssynchrony and RR may differ according to criteria used to determine RR. Methods: Thirty patients with advanced heart failure, wide QRS complex, and LVEF ≤35% were included. Echocardiography coupled with tissue Doppler imaging was performed at baseline, and repeated at 1 and 6 months in follow-up. Patients were divided into RR and no-remodeling groups according to 10% decrease in left ventricular end-systolic volume (LVESV) and/or 25% increase in LVEF. Results: Left ventricular dyssynchrony improvement was significant at the first month in both the RR and no-remodeling groups according to LVESV decrease. Left ventricular dyssynchrony improvement was continued in the RR group; however, it did not improve significantly in the no-remodeling group. Left ventricular dyssynchrony improvement was significant at the first and sixth month in the RR and no-remodeling groups according to LVEF increase. Conclusions: Our study suggests that LV dyssynchrony improvement plays an important role in the development of RR according to decrease in LVESV. Reverse remodeling according to the increase in LVEF was developed independently from LV dyssynchrony improvement. The improvement in LV dyssynchrony is a necessary but not sufficient explanation for improvement in LVEF and LVESV. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

The benefits of taking of aspirin, clopidogrel, and warfarin in relation to cardiovascular mortality and re-hospitalization in chronic heart failure (HF) patients have been called into question. We examined the outcomes (cardiac mortality and/or HF re-hospitalization) in patients discharged from our hospital between January 2003 and July 2009 after hospitalization for chronic decompensated HF. Of 580 HF patients (mean age, 63 ± 13 years; mean ejection fraction, 26 ± 9%, 63% with coronary disease and 37% without coronary disease), 207 patients (36%) died due to cardiovascular reasons, and 313 (54%) required HF re-hospitalization for decompensated HF during a 39 ± 14 month follow-up period. 101 (17%) patients were taking clopidogrel during enrollment in the study. When comparing patients who were on clopidogrel treatment with those who were not, clopidogrel was found to have a beneficial effect on cardiac mortality (27 vs. 38%, P = 0.04). In conclusion, in this observational prospective study, patients who used clopidogrel showed decreased cardiac mortality [HR, 0.566 (95% CI 0.332-0.964), P = 0.036] compared to patients who did not take clopidogrel. Clopidogrel had a beneficial effect on the survival of chronic HF patients in the long term.

Myocardial non-compaction (NC) is a rare genetic cardiomyopathy commonly believed to develop an intrauterine arrest of endomyocardial morphogenesis. NC is characterized by markedly hypertrabeculations in left ventricle or both ventricles with deep intertrabecular recesses. NC is usually seen isolated, but sometimes other congenital heart abnormalities may accompany to the myocardial NC. In this article we have presented an adult patient with biventricular myocardial NC cardiomyopathy accompanied by severe valvular pulmonary stenosis and patent foramen ovale.

Purpose The aim of this study was to investigate the long-term prognosis of non-interventionally followed patients with myocardial bridge and angiographic milking of the left anterior descending (LAD) coronary artery. Methods All of the coronary angiography records from May 2000 to November 2007 were reevaluated and patients who had more than 70% narrowing during systole on LAD were eligible for the present study. Follow-up was carried out by physical examination, echocardiography, and treadmill exercise testing. The clinical situations of the patients, medical treatment at the time of follow-up, and experienced events (death, myocardial infarction, or revascularization) were recorded. Results There were 59 eligible patients (44 male, 74.6%). The mean age of the patients was 54 ± 11 years. The bridges were located in the proximal, mid, and distal portion of the LAD in 17 (28.8%), 20 (33.9%), and 22 (37.3%) patients, respectively. Distributions of the narrowing degree were as follows: between 70% to 89% in 33 (56%) patients and 90% to 100% in 26 (44%) patients. Mean follow-up duration of the group was 37 ± 13 months (range 15–65 mo). The clinical presentation during follow-up was stable angina in 9 (15.3%) cases, atypical angina in 12 (20.3%), atypical chest pain in 13 (22%), dyspnea in 3 (5.1%), and syncope in 3 (5.1%) cases. There were no experienced events and/or hospitalizations related to cardiac disease. Echocardiographic examination revealed normal systolic ventricular function. Only 17 (28.8%) patients continued to use medication. Most of them were on β-blocker therapy. Conclusion Patients with myocardial bridges and angiographic milking of the LAD coronary artery have a good long-term prognosis. Copyright © 2009 Wiley Periodicals, Inc.

Aims Patients having conduction disease and indications for a standard pacemaker implantation are treated with right ventricular (RV)-based pacemaker therapy. The aim of this study was to investigate echocardiographic and clinical effects of RV and left ventricular (LV)-based pacing in patients with standard pacemaker indication and LV dysfunction. Methods and results Thirty-nine patients with symptomatic bradycardia due to sinus or atrioventricular nodal dysfunction and having absolute standard pacemaker indication, low LV ejection fraction (EF) (35–50%) and QRS duration

Background— Prior studies have demonstrated an inconsistent association between patients’ arrival time for acute myocardial infarction (AMI) and their subsequent medical care and outcomes. Methods and Results— Using a contemporary national clinical registry, we examined differences in medical care and in-hospital mortality among AMI patients admitted during regular hours (weekdays 7 am to 7 pm ) versus off-hours (weekends, holidays, and 7 pm to 7 am weeknights). The study cohort included 62 814 AMI patients from the Get With the Guidelines–Coronary Artery Disease database admitted to 379 hospitals throughout the United States from July 2000 through September 2005. Overall, 33 982 (54.1%) patients arrived during off-hours. Compared with those arriving during regular hours, eligible off-hour patients were slightly less likely to receive primary percutaneous coronary intervention (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 to 0.98), had longer door-to-balloon times (median, 110 versus 85 minutes; P Conclusions— Despite slightly fewer primary percutaneous coronary interventions and overall revascularizations and significantly longer door-to-balloon times, patients presenting with AMI during off-hours had in-hospital mortality similar to those presenting during regular hours.

Cardiac syndrome X defines patients with typical angina, a positive exercise ECG stress test and angiographically documented normal coronary arteries. In previous studies, post-stress prolonged left ventricular dysfunction (PLVD) using gated SPECT (G-SPECT) had been well correlated with myocardial perfusion abnormalities and degree of stenotic vessels in CAG in patients with coronary artery disease. However, evaluation of left ventricular myocardial perfusion, wall motion and left ventricular ejection fraction (LVEF) in patients with cardiac syndrome X, using G-SPECT had not been studied yet. Thus, the aim of this study was to analyse PLVD using (99m)Tc-MIBI GSPECT in patients with cardiac syndrome X.Of the patients in whom G-SPECT was performed in our institution between 2004 and 2006, 17 patients with anginal chest pain, positive exercise ECG stress test and normal coronary angiograms were retrospectively included to the study (group I). Fifteen patients with normal myocardial perfusion and another 15 patients with ischaemia on G-SPECT were selected as control groups (groups II and III). (99m)Tc-MIBI G-SPECT was performed for all patients according to 2 day (stress-rest) protocol. Stress and rest LVEF were derived automatically (SLVEF and RLVEF). Difference LVEF (DLVEF) (stress-rest) was calculated. Semiquantitative analyses were made both for myocardial perfusion and wall motion (WM), using a 20-segment model and a 5-point scoring system. DLVEF, perfusion and WM scores of all groups were compared among three groups and relationship between DLVEF, perfusion and WM scores were evaluated.Abnormal perfusion were detected in eight (47.1%) of patients, while the remaining nine (52.9%) had normal myocardial perfusion, in group I. Six of 17 (35.3%) patients in group I had post-stress WM abnormalities. Mean of DLVEF values were -3.1+/-3.0%, 4.4+/-2.0% and -6.0+/-5.1% in groups I, II and III, respectively (P0.05 for group II vs. group I and group III; P0.05 for group I vs. group III). LVEF response impairment (or =5% increase from rest to post-stress images) was found in 17 (100%), seven (46.6%), 14 (93.3%) of patients in groups I, II and III, respectively.Abnormal myocardial perfusion, concordant transient segmental WM abnormalities and LVEF response impairment are not uncommon in patients with cardiac syndrome X of this cohort of the study population. Therefore, post-stress prolonged stunning may be attributed to these findings in some of cardiac syndrome X patients as in true ischaemic patients. However, further studies with larger number of subjects and long-term follow-up are necessary to support these findings.

Steinert's disease (Dystrophia myotonica type 1) is an autosomal dominant neuromuscular disease characterized by myotonia, muscle weakness, frontal balding, cataracts, cardiac conduction abnormalities, especially long PR interval and wide QRS complex. Although subclinical mild myocardial dysfunction may be detected in this syndrome, overt myocardial dysfunction with heart failure called as "myotonic heart disease" is not frequent. Cardiac resynchronization therapy is an effective treatment modality to improve morbidity and mortality in patients with intraventricular conduction delay and congestive heart failure. We report improvement of cardiac dyssynchrony and symptoms of heart failure with biventricular pacing in a 37-year-old male patient with overt myotonic heart disease, PR segment prolongation, and complete left bundle branch block.

Naxos disease is an autosomal recessively inherited familial syndrome characterized by woolly hair, palmoplantar keratoderma and a cell adhesion cardiomyopathy, especially arrhythmogenic right ventricular dysplasia (ARVD). Carvajal syndrome is a variant of Naxos disease in which curly or woolly hair, biventricular--predominantly left ventricular involvement were seen. Mutations in genes encoding the cell adhesion proteins like plakoglobin and desmoplakin were related with these syndromes. We report a 17-year-old boy and his family findings with curly hair, palmoplantar hyperkeratosis, ARVD and left ventricular involvement. The family was of Arabic origin, and a third-degree consanguinity was reported between the parents. They are from east part of Turkey and there were no relatives from Cyclades Island (Greece). Patient's younger brother had ARVD without cutaneous manifestations of the syndrome and his grand father had mild ARVD, curly hair and palmoplantar hyperkeratosis.

Objective: Hypertension is associated with endothelial dysfunction and reduced nitric oxide (NO) activity. Recent observations have shown a significant correlation between endothelial and diastolic dysfunction in cardiovascular disease. The aim of this study was to assess the effect of nebivolol, a β-blocker with NO-mediated vasodilatation properties, on endothelial function in newly diagnosed, previously untreated, hypertensive patients with and without diastolic dysfunction.

The effects of thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) have been evaluated in several studies. The aim of the present study was to evaluate postprocedural outcomes in elderly STEMI patients who have a tendency for vasoconstruction and decreased coronary flow reserve.A total of 124 patients (aged ≥65 years) with STEMI who underwent primary PCI (71.2% men, 29.8% women, mean age 74 ± 7 years) were enrolled in the study. Patients were divided into two groups according to intervention with and without TA. Acute angiographic, electrocardiographic and echocardiographic results were compared between the two groups.TA was carried out in 42 patients (33.8%). Baseline clinical characteristics and predischarge echocardiographic features did not differ between TA(+) and TA(-) patients (ejection fraction 37.26 ± 8.91 vs 38.53 ± 11.18, P = 0.558, wall motion index 1.69 ± 0.38 vs 1.76 ± 0.37, P = 0.316, septal E' 0.058 ± 0.022 vs 0.053 ± 0.015, P = 0.267, E/E' 11.82 ± 4.30 vs 13.12 ± 5.09, P = 0.370). Acute angiographic and electrocardiographic results did not differ between the two groups, but were slightly better in the thrombectomy group than those without TA corrected TIMI frame count (31.63 ± 16.33 vs 34.97 ± 15.81, P = 0.197, TIMI-3 88.1% vs 79.3%, P = 0.223, ST segment resolution 81.3% vs 70.3%, P = 0.250).Thrombectomy during primary PCI has no effect on postprocedural outcomes in an elderly group with STEMI. Geriatr Gerontol Int 2015; ●●: ●●-●●.

The appropriate size, accurate alignment and correct positioning of transcatheter aortic valves (TAVIs) at the point of deployment are emphasized as key factors in placement and fixation of the devices. Presence of a sigmoid left ventricular septum in the patient is one of the important limitations of TAVIs, especially with the Edwards- Sapien Valve (ESV), due to the risk of aortic embolization of the prosthesis. In cases of a pronounced sigmoid septum, transapical implantation of the ESV or the usage of a Medtronic CoreValve (MCV) is generally recommended. However, severe left ventricular hypertrophy and sigmoid septum are also risk factors for the development of conduction disturbances with the usage of MCV. The depth of implantation of MCV within the left ventricular outflow tract and larger or significantly oversized prostheses have also been reported as important predictors of permanent pacemaker (PPM) requirement after MCV implantation. Thus, recent reports indicate that there may be less need for a PPM if a high implantation technique is used to place the MCV at a short implantation depth. In this report, we present the high implantation technique under rapid pacing during transcatheter aortic MCV implantation in a surgically high-risk aortic stenosis patient with sigmoid left ventricular hypertrophy and a large aortic annulus.

Percutaneous closure of paravalvular leaks has emerged as an alternative to repeated surgeries. Different percutaneous techniques and various devices have been used, off-label, for paravalvular leak closure. For mitral leaks, antegrade transseptal, retrograde transfemoral, and retrograde transapical techniques have been developed. In the antegrade transseptal approach, an arteriovenous guidewire loop is often created to advance the delivery sheath. In retrograde transfemoral closure, the wire in the left atrium is usually snared after transseptal puncture, to pull it from the femoral vein. The delivery sheath and closure device will subsequently be deployed from the left atrium. Each of these procedures takes time, is costly, and increases the risk of complications. We present the cases of 3 patients in whom we closed mitral paravalvular leaks by means of a retrograde transfemoral approach, with use of an Amplatzer™ Duct Occluder II device and without the construction of an arteriovenous wire loop. We think that this approach can be very useful in a specific group of patients—reducing costs, fluoroscopy times, and complications related to transseptal puncture and construction of an arteriovenous wire loop. In our institution, this reported technique is routinely used for mitral paravalvular leak closure.

PP-051 Warfarin use and associated outcomes in patients with chronic heart failure (HF) have not been well described previously. We hypothesized that warfarin is associated with lower risks of cardiovascular mortality in patients with sinus rhythm, atrial fibrillation and pacemaker rhythm. We

permanent VDD pacamaker implantation for symptomatic bradycardia 9 years ago at another institution, was admitted to the hospital for pacemaker battery change. Physical examination revealed blood pressure of 110/80 mmHg, heart rate of 50 bpm, respiratory rate of 20 breaths per minute. A grade III/ VI pansystolic murmur with maximal intensity was heard at the left sternal border. Electrocardiography showed ventricular pacemaker spikes followed by right bundle branch block pattern. Posterior-anterior chest X-ray suggested atypical lead position. The pacemaker battery was changed successfully and pacemaker functions were normal. Transthoracic echocardiography was done as a routine follow-up before discharge. Transthoracic echocardiography revealed left ventricular hypertrophy, left atrial and right ventricular dilatation, a central type ventricular septal defect with a diameter of 5 mm (maximal gradient = 46 mmHg, Qp/Qs = 1.3) and a patent foramen ovale with the ventricular lead crossing the defect (Fig. 1). Transesophageal echocardiography revealed a thrombus with a 5 · 6 mm diameter in the interatrial septum (Fig. 2). Coronary angiography revealed normal coronary arteries and Qp/Qs was 1.35. The patient had a history of pacemaker battery change in 2002 and had normal lead functions on routine follow-up. The patient underwent surgical lead extraction and closure of the patent foramen ovale without any complication. Ventricular septal defect was not repaired. After surgery VDD pacemaker was implanted with success.

Transcatheter aortic valve implantation (TAVI) has emerged as a life-saving therapy in patients with severe aortic valve stenosis who are considered to be high-risk surgical candidates. However, there is a paucity of data on the long-term survival and quality-of-life in very old patients undergoing TAVI. Here, the case is reported of a now 104-year-old patient who underwent percutaneous transfemoral TAVI with a CoreValve prosthesis at the age of 99 years; details of his four-year outcome data are also provided. To best of the authors' knowledge, this patient is the oldest reported to have undergone TAVI, and is currently living with good functional status more than four years after the intervention.

Complex ostium secundum type atrial septal defect (ASD) is a definition used for large (stretched diameter over 26 mm with deficient rim) or multiple ASDs or multi-fenestrated septum or ASDs with redundant and aneurysmal septal rims. Compared to simple defects, transcatheter ASD closure with Amplatzer septal occluder (ASO) is relatively challenging in these cases, and different techniques have been defined to increase procedure success. We report three adult patients with complex ostium secundum type ASDs that were closed with ASO device using three different techniques. The first case was a 36-year-old female patient with complaints of dyspnea, palpitation and fatigue. A complex ostium secundum type ASD was diagnosed, and the defect was closed with a 36 mm ASO device using a left upper pulmonary vein technique. The second case was a 47-year-old female patient with complaints of dyspnea and palpitation. A large and complex ASD was detected, and the defect was closed with a 28 mm device using a left atrial roof technique supported by non-inflated balloon. The third case was a 40-year-old female patient who presented with complaints of dyspnea and palpitation. Complex ASD was diagnosed, and the defect was closed with a 32 mm device using a partially inflated balloon technique. In large and complex ASDs, the classical implantation technique of an ASO device may fail at any time. The knowledge and application of different techniques that orient the left atrial disc parallel to the septum may increase the procedure success and decrease complications.

OBJECTIVE To investigate comorbidities that predict cardiac mortality and re-hospitalization in chronic heart failure (CHF) patients. METHODS Five hundred eighty patients (mean age 63 ± 13 years, 373 male, 207 female, mean ejection fraction (EF) 26 ± 9%) with mild, moderate or severe CHF [NYHA class II-IV] were included in this prospective observational study. We evaluated all comorbidities such as history of ischemic stroke, coronary artery disease, peripheral arterial disease, chronic obstructive lung disease, hypertension, diabetes mellitus and chronic kidney disease in CHF patients who were hospitalized due to decompensated heart failure in Kocaeli University, Faculty of Medicine's Hospital between January 2003 and July 2009. Cox regression and Kaplan-Meier survival analyses were used to establish predictors of unfavorable outcomes. RESULTS Of 580 patients 207 (36%) patients died due to cardiovascular reasons. In multivariable Cox regression analysis age (HR-1.06, 95% CI 1.04-1.08, p

The aim of this study was to investigate whether the amount of urinary albumin concentration (UAC) or urinary albumin to creatinine ratio (UACR) is more strongly associated with angiographically documented coronary artery disease (CAD).A total of 199 consecutive patients [11 9(60%) male, 80 (40%) female, mean age =57±10] undergoing diagnostic coronary angiography were included in the study. Significant coronary artery disease was defined as a stenosis equal to or above 50% in the main coronary artery or in one of the other branches. UAC and UACR were calculated from the urine. Baseline clinical parameters, UAC and UACR were compared between subjects with and without CAD. Factors predicting CAD were evaluated by multivariate analysis.Baseline clinical and laboratory characteristics of patients with and without CAD were not different except for a slightly male predominance in patients with CAD. Patients with CAD had significantly higher UACs and UACRs than patients without CAD (32.14±31.27 mg/day vs. 15.61±16.70 mg/day, p=0.01; 9.11±7.42 mg/g vs. 4.80±3.28 mg/g, p=0.009). A positive correlation was found between Gensini score and UACR (p=0.01), whereas no correlation was found between Gensini and UAC. UACR was the only significant parameter for the presence of CAD in the multivariate analysis adjusted for age, sex, other well known CAD risk factors, UAC and UACR.Our preliminary results suggest that UACR is more closely associated with angiography documented CAD than is the level of UAC itself, but UACR maybe more significantly associated with angiography documented CAD than with the levels of UAC.

Although low levels of free triiodothyronine and high levels of brain natriuretic peptide have been shown as independent predictors of death in chronic heart failure patients, few studies have compared their prognostic values. The aim of this prospective study was to measure free triiodothyronine and brain natriuretic peptide levels and to compare their prognostic values among such patients.A total of 334 patients (mean age, 62 ± 13 yr; 218 men) with ischemic and nonischemic dilated cardiomyopathy were included in the study. The primary endpoint was a major cardiac event.During the follow-up period, 92 patients (28%) experienced a major cardiac event. Mean free triiodothyronine levels were lower and median brain natriuretic peptide levels were higher in patients with major cardiac events than in those without. A significant negative correlation was found between free triiodothyronine and brain natriuretic peptide levels. Receiver operating characteristic curve analysis showed that the predictive cutoff values were2.12 pg/mL for free triiodothyronine and686 pg/mL for brain natriuretic peptide. Cumulative survival was significantly lower among patients with free triiodothyronine2.12 pg/mL and among patients with brain natriuretic peptide686 pg/mL. In multivariate analysis, the significant independent predictors of major cardiac events were age, free triiodothyronine, and brain natriuretic peptide.In the present study, free triiodothyronine and brain natriuretic peptide had similar prognostic values for predicting long-term prognosis in chronic heart failure patients. These results also suggested that combining these biomarkers may provide an important risk indicator for patients with heart failure.

Several studies exist on the left atrial appendage function (LAA) in permanent atrial fibrillation (AF). However, knowledge about the right atrial appendage (RAA) function is limited. We investigated RAA function with TEE and tissue Doppler imaging (TDI) in permanent AF patients with different etiologies and evaluated predictive parameters of right atrial spontaneous echo contrast (SEC) and thrombi.Patients with permanent AF developed due to three different etiologies (20 mitral stenosis, 44 hypertension, 20 hyperthyroidism) and 23 subjects with sinus rhythm were included into the study. RAA was examined with TEE and pulsed-wave and TDI velocities of RAA were measured.Both PW-Doppler and TDI velocities were significantly impaired in all AF groups compared to controls. The lowest velocities were recorded in mitral stenosis patients. Right atrial moderate-severe SEC was observed in 75% of the mitral stenosis patients, in 25% of hypertensive patients, and in 30% of hyperthyroidism patients. Right atrial thrombus was observed in 25% of mitral stenosis, 4.5% of hypertension, and in none of the hyperthyroidism patients. In the multivariate analysis, the most important parameter associated with the severity of RAA SEC was the percent change in RAA area (B =-0.034, P = 0.03).In patients with permanent AF, impairment of RAA function and development of right atrial SEC-thrombus are closely related to the underlying etiology. These results suggested that evaluation of RAA functions may have an incremental value over the assessment of the LAA for determining thromboembolic risk.

Background — Spontaneous echocardiographic contrast (SEC) is a frequent finding in patients with dilated cardiomyopathy (DCM). In this study, we have investigated the frequency and clinical correlates of aortic-SEC (Ao-SEC) in patients with DCM.Methods — Ninety-two consecutive DCM patients (63 men, 29 women, mean age 60 ± 11 years) underwent transthoracic and transoesophageal echocardiography.Results — Ao-SEC was found in 53 patients (58%). It was associated with: (i) a lower cardiac index (P< 0.001); (ii) left atrial-SEC (P< 0.001); (iii) left ventricular-SEC (P = 0.008); (iv) a larger aortic root (P= 0.02); (v) the presence of complex aortic atherosclerotic plaques (P< 0.001).The significant determinant of thromboembolism was left-atrial SEC (P= 0.03).We did not find a significant correlation between Ao-SEC and thromboembolism.Conclusion — Most of the patients who developed embolic events in the follow-up period had Ao-SEC.Thromboembolism is rather associated with left-atrial SEC than with Ao-SEC.

Emerging evidence indicates the prognostic importance of cystatin C (Cys-C) in patients with coronary artery disease. However, whether Cys-C concentrations are associated with adverse clinical events among patients with acute coronary syndromes (ACS) have not been studied extensively. We compared the long-term prognostic efficacy of Cys-C with other markers of renal dysfunction, inflammation and systolic dysfunction in patients with ACS.Serum levels of Cys-C, high sensitive C-reactive protein (hs-CRP), brain natriuretic peptide (BNP) and creatinine were measured in 160 patients with ACS (112 males, 48 females, mean age 60+/-10 years) on admission. Primary end point of the study was major adverse cardiac events (MACE) defined as the combination of cardiac death, non-fatal myocardial infarction and recurrent rest angina that required hospitalization within 12 months of follow-up. During the follow-up period, 42 (26%) patients met the MACE criteria. The occurrence of MACE was significantly higher among patients with higher Cys-C levels. In multivariate analysis, Cys-C was the most important parameter associated with the occurrence of MACE (OR=9.62, 95% CI=2.3-40.5, p0.001). ROC curve analysis showed that the predictive cut-off value of Cys-C for MACE was 1051ng/ml. In the Cox regression analysis adjusted for multiple risk factors, Cys-C was found as the most powerful predictor for MACE (RR=9.43, 95% CI=4.0-21.8, p0.001).The results of the present study indicate that admission levels of Cys-C may be a good prognostic indicator of recurrent cardiovascular events in patients with ACS. Further studies are needed to confirm these results.

Background: Atrial fibrillation (AF) occurs due to various etiologies that carry different risks for thromboembolism. However, the effect of different etiologies on left atrial appendage (LAA) function has not been investigated. This study aimed to examine the LAA function in AF that occurred under various etiologies and to compare the findings with a novel tissue Doppler imaging (TDI) technique by using transesophageal echocardiography (TEE). Methods: LAA function was assessed in 84 patients with permanent AF according to various etiologies [mitral stenosis in 20 (24%), hypertension in 44 (52%), and hyperthyroidism in 20 (24%) patients] and in 23 controls with sinus rhythm. LAA area change, PW-Doppler and tissue velocities of LAA were measured. The presence of SEC or thrombus and their relation to LAA function was evaluated. Results: LAA velocities were lowest in mitral stenosis and highest in hyperthyroidism. Moderate–severe LAA SEC was detected in 61 and thrombi in 23 patients. Factors associated with the severity of SEC were the percentage of the LAA area change, PW-Doppler peak emptying velocity, and TDI septal wall downward velocity. The percent of the LAA area change and PW-Doppler peak emptying velocity were the significantly related factors for the presence of thrombi (OR = 0.84, 95% CI = 0.74–0.95, P = 0.005 and OR = 0.85, 95% CI = 0.74–0.98, P = 0.02, respectively). Conclusion: LAA function deteriorated most severely in mitral stenosis and least in hyperthyroidism. The LAA area change and PW-Doppler emptying velocity were important predictors for SEC or thrombi. Although TDI was not superior to classical methods, it provided complementary data to PW-Doppler velocities for predicting SEC and thrombi.

Underlying predisposition for a heightened inflammatory response is postulated as one of the mechanisms for elevated high-sensitivity C reactive protein (hs-CRP) levels in patients with acute coronary syndrome (ACS). It is unclear whether metabolic syndrome (MetS) may cause a predisposition for heightened hs-CRP response in patients with ACS. The aim of this study is to investigate the interaction between hs-CRP levels and presence of MetS in patients with and without ACS.Two hundred and seventy-three consecutive patients presenting with a first ACS event and 261 MetS patients without any ACS event were included to the study. The study participants were divided into three groups as MetS (+) ACS (-) [n=261], MetS (-) ACS (+) [n=110], and MetS (+) ACS (+) [n=163]. Median levels of hs-CRP were compared between and within the three groups.Hs-CRP levels were lowest in MetS (+) ACS (-) subjects and highest in MetS (+) ACS (+) patients. Factors associated with hs-CRP levels were troponin elevation, presence of ACS, body mass index (BMI), and presence of MetS (R(2)=0.26, p0.01). Predictors of elevated hs-CRP levels (0.3mg/dl) were the presence of ACS (OR=3.6, 95% CI=1.9-6.5, p0.01), presence of MetS (OR=2.1, 95% CI=1.0-4.0, p=0.02), troponin elevation (OR=5.7, 95% CI=2.8-11.5, p0.01) and BMI (OR=1.1, 95% CI=1.0-1.1, p0.01).The presence of MetS had an impact on the increase in hs-CRP levels observed with an ACS event in the study population. These findings suggested that a heightened baseline inflammatory status of MetS may predispose ACS patients to an augmented hs-CRP response.

The effect of Ramadan fasting on ambulatory blood pressure in hypertensive patients using combination drug therapy

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

Objective: To investigate the relation between serum high sensitivity (hs) C reactive protein (CRP), proinflammatory cytokine concentrations, proinflammatory to anti-inflammatory cytokine ratios and long-term prognosis in patients with non-ST elevation acute coronary syndrome (NSTEACS). Design: Prospective follow-up study for the first six months and then for the first year after admission to hospital. Setting: Tertiary referral centre. Patients: 80 patients (60 men, 20 women, mean age 60 (SD 10) years) with NSTEACS and moderate to high TIMI (Thrombolysis In Myocardial Infarction) risk scores. Interventions: Blood samples from patients with NSTEACS were obtained at the time of admission. Serum concentrations of hs-CRP, (hs) pro-inflammatory (interleukin (IL) -1β, IL-6, tumour necrosis factor α) and (hs) anti-inflammatory (IL-10) cytokines were analysed and proinflammatory to anti-inflammatory cytokine ratios were calculated by dividing proinflammatory cytokine concentrations by anti-inflammatory cytokine IL-10. Main outcome measure: The primary end point of the study was new coronary events (NCE) defined as the combination of cardiac death, non-fatal myocardial infarction and recurrent rest angina that required hospitalisation within 12 months of follow up. Results: During the one-year follow-up period, 23 patients (29%) met the NCE criteria. Concentrations of hs-CRP, IL-1β and IL-6 and ratios of IL-1β:IL-10 and IL-6:IL-10 were significantly higher in patients with NCE than in patients without NCE. In the logistic regression analysis, IL-6:IL-10 ratio was the most important predictor for NCE (p = 0.006) with an odds ratio of 2.24 (95% CI 1.26 to 3.97). Conclusions: Cytokine concentrations and proinflammatory to anti-inflammatory cytokine ratios may be useful markers for predicting vascular risk in patients with NSTEACS.

BACKGROUND: The aim of this study was to evaluate metabolic syndrome frequency, cardiovascular risk profile and premature carotid artery atherosclerosis in patients with polycystic ovary syndrome (PCOS) especially during early adulthood. METHODS: A case‐control study was conducted on 43 young women (18‐22 years of age) with PCOS and 43 age-matched volunteer controls. Anthropometrical measurements, hormone levels, lipid and glucose profile were obtained from all subjects. Two different criteria were used to assess metabolic syndrome (MS) frequency. Common carotid artery intima-media thickness (IMT) was measured and stepwise multiple linear regression analysis was used to identify the independent cardiovascular risk factors that predict IMT. RESULTS: MS was diagnosed in 11.6% (n 5 5) of women with PCOS compared to no cases in the control group (P 5 0.02). The mean IMT was significantly higher in PCOS subjects (0.746 6 0.106mm) compared to controls (0.608 6 0.105mm, P< 0.001). Among many cardiovascular risk factors evaluated, the diagnosis of PCOS, increased body mass index and decreased sex hormone-binding globulin were significant independent predictors of increased IMT. CONCLUSIONS: These findings indicate that adolescence may be a more appropriate time to intervene for PCOS patients, as many cardiovascular risks are already present during early adulthood. As far as IMT is concerned, mechanisms other than hyperandrogenaemia and obesity might be operating as causative factors.

The role of reverse remodelling of the right and left ventricle and symptom improvement after biventricular upgrade {#article-title-2} Background and objectives The role of right (R) and left (L) ventricular (V) reverse remodelling in symptom improvement after biventricular upgrade is unclear. Methods Tomographic radionuclide angiocardiographic RV and LV end-diastolic (EDV, mL) and end-systolic (ESV, mL) and New York Heart Association heart failure class (NYHA) were determined before and 3–6 months after upgrading from persistent RV pacing to persistent biventricular pacing in 19 patients. Results Symptoms improved (a decline in at least one NYHA class) in 9 patients (2.89 ± 0.33 to 1.67 ± 0.5) with no improvement in 10 (2.6 ± 0.52 to 2.6 ± 0.52). During chronic RV pacing and before biventricular upgrade, patients with symptom compared with those without symptom improvement had significantly larger LV EDV (221 ± 75 vs. 160 ± 42, P = 0.04). After biventricular upgrade, in patients with symptom improvement, significant declines in LV EDV (221 ± 75 to 180 ± 54, P = 0.04) and ESV (147 ± 58 to 109 ± 46, P = 0.01) occurred; no significant changes occurred in RV EDV (256 ± 64 vs. 220 ± 33) and ESV (157 ± 74 vs. 122 ± 43). After biventricular upgrade, patients without symptomatic improvement showed no significant changes in LV and RV volumes. Conclusions Symptomatic improvement after upgrading from chronic RV to biventricular pacing was associated with a larger baseline LV EDV and subsequent significant reduction in LV EDV and ESV. Reverse remodelling of the LV but not the RV after biventricular pacing upgrade was associated with symptom improvement. # CRT response score predicts the effects of cardiac resynchronization therapy {#article-title-3} Background and objectives The effectiveness of cardiac resynchronization therapy (CRT) has been verified by large multi-centre studies, but non-response phenomenon occurs in ∼30% of patients according to the indications of CRT recently. This study was designed to evaluate the factors that affect the effects of CRT, summarize CRT response score to predict clinical effects. Methods From December 2001 to August 2009, 110 patients with chronical heart failure were enrolled in this study. The patients underwent a clinical examination, 12-lead electrocardiography, echocardiographic evaluations before implantation. Patients were divided into control and response group which was defined as a decrease in left ventricular end-diastolic diameter of ≥15% at 6 months after operation. The follow-up duration was 12 months. The clinical endpoint considered was cardiovascular death and hospitalization due to heart failure. Results CRT-P/D devices were successfully implanted in 107 patients. Of the patients, 61.3% showed a response to CRT. Multiple logistic regression identified an independent association between duration of heart failure, ischaemic cardiomyopathy, ΔQRS, septal-to-posterior wall motion delay (SPWMD), and effects of CRT. Four score was assigned to duration of heart failure ≥5.0 years, ischaemic cardiomyopathy, ΔQRS 150 ms: what are the LV conduction delays in RBBB vs. LBBB? {#article-title-4} Rationale Surface QRS duration (QRSd) exceeding 150 ms predicts greater likelihood of CRT response in patients with LV dysfunction (HF). The reason may be greater delay of LV activation time (LVAT) since the premise of CRT requires late LV activation. However, the relation of QRSd and configuration to LVAT is unknown. This was assessed. Methods In HF patients (LV ejection fraction 23 ± 8%, n = 85) with QRS >120 ms left bundle branch block (LBBBHF, n = 54) and right bundle branch block (RBBBHF, n = 31), LVAT was estimated by interval from QRS onset to basal inferolateral LV depolarization during intrinsic conduction. Results QRSd in LBBBHF did not differ to RBBBHF (161 ± 29 vs. 165 ± 18 ms, P = NS), but LVAT was greater (136 ± 33 vs. 100 ± 24 ms, P 150/ < 150 ms (see figure). LVAT correlations with QRS duration were RBBBHF: P = 0.1; LBBBHF: P < 0.001. ![Figure][1] Conclusion LV activation delay in patients with LV dysfunction is greater when QRSd >150 ms. However, QRSd >150 ms with RBBBHF is less likely to contain prolonged LVAT. The probability distribution of LVAT according to QRS duration and configuration may determine the likelihood of response if CRT is applied universally to HF patients with QRS >150 ms. # Relationship between dyssynchrony improvement and reverse remodelling {#article-title-5} We aimed to investigate reverse remodelling (RR) according to a decrease in left ventricular end-systolic volume (LVESV) and an increase in left ventricular ejection fraction (LVEF) and their relationship between dyssynchrony improvements. Thirty patients with severe heart failure, scheduled for implantation of a CRT device, were identified as echocardiographic responders by 10% decrease in LVESV and/or 25% increase in LVEF. Intraventricular dyssynchrony was measured with TDI. Patients were divided in RR developed and non-developed groups. RR according to LVESV was developed in 18, 22, and 22 patients at 1st, 3rd, and 6th months, respectively. RR according to LVEF was developed in 10, 14, and 18 patients at 1st, 3rd, and 6th months, respectively. Ventricular dyssynchony improvement was significant at the end of the first month in both of RR developed and non-developed groups according to LVESV. Dyssynchrony improvement was continued in the RR developed group. However, it does not improve regularly in the RR non-developed group. Dyssynchrony improvement was significant at the end of the first month in the RR developed and non-developed patient groups according to LVEF and there was not any difference at the end of the 6th month. Ventricular dyssynchrony improvement plays an important role in RR according to LVESV. Synchronized contraction of the interventricular non-contracting chamber areas with CRT may be one of the reasons. However, there was not any difference in dyssynchrony improvement in RR developed and non-developed groups according to LVEF. RR in these groups may develop with a different mechanism. # Cardiac resynchronization therapy in heart failure patients with narrow QRS {#article-title-6} Background Cardiac resynchronization therapy (CRT) is an established therapy for severe symptomatic heart failure with depressed left ventricle (LV) systolic function and a wide QRS >120 ms. However, only 30% heart failure patients will fulfil these criteria. Studies have demonstrated benefits of CRT with narrow QRS