Multi-Center Experience of Coronary Artery Perforation During Percutaneous Coronary Intervention: Clinical and Angiographic Characteristics, Management, and Outcomes Between 2010 and 2020.

BACKGROUND: Coronary artery perforations are one of the most feared, rare, and catastrophic complication of percutaneous coronary intervention. Despite the remarkable increase in coronary angiography and percutaneous coronary intervention, there is no large database that collects coronary artery perforation for the Turkish population. Our study aimed to report our experience over a 10-year period for clinical and angiographic characteristics, management strategies, and outcomes of coronary artery perforation during the percutaneous coronary intervention at different cardiology departments in Turkey. METHODS: The study data came from a retrospective analysis of 48 360 percutaneous coronary intervention procedures between January 2010 and June 2020. A total of 110 cases who had coronary artery perforation during the percutaneous coronary intervention were found by angiographic review. Analysis has been performed for the basic clinical, angiographic, procedural characteristics, the management of coronary artery perforation, and outcome of all patients. RESULTS: The coronary artery perforation rate was 0.22%. Out of 110 patients with coronary artery perforation, 66 patients showed indications for percutaneous coronary intervention with acute coronary syndrome and 44 patients with stable angina pectoris. The most common lesion type and perforated artery were type C (34.5%) and left anterior descending (41.8%), respectively. The most observed coronary artery perforation according to Ellis classification was type III (37.2%). Almost 52.7% of patients have a covered stent implanted in the perforated artery. The all-cause mortality rate of coronary artery perforation patients in the hospital was 18.1%. CONCLUSION: The observed rate of coronary artery perforation in our study is consistent with the studies in this literature. However, the mortality rates related to coronary artery perforation are higher than in other studies in this literature. Especially, the in-hospital mortality rate was higher in type II and type III groups due to perforation and its complications. Nevertheless, percutaneous coronary intervention should be done in selected patients despite catastrophic complications.

Frontal QRS/T angle can predict mortality in COVID-19 patients.

AIMS: The frontal QRS-T (fQRS) angle has been investigated in the general population, including healthy people and patients with heart failure. The fQRS angle can predict mortality due to myocarditis, ischaemic and non-ischaemic cardiomyopathies, idiopathic dilated cardiomyopathy, and chronic heart failure in the general population. Moreover, no studies to date have investigated fQRS angle in coronavirus disease 2019 (COVID-19) patients. Thus, the purpose of this retrospective multicentre study was to evaluate the fQRS angle of COVID-19 patients to predict in-hospital mortality and the need for mechanical ventilation. METHODS AND RESULTS: An electrocardiogram was performed for 327 COVID-19 patients during admission, and the fQRS angle was calculated. Mechanical ventilation was needed in 119 patients; of them, 110 died in the hospital. The patients were divided into two groups according to an fQRs angle >90° versus an fQRS angle ≤90°. The percentages of mortality and the need for mechanical ventilation according to fQRS angle were 67.8% and 66.1%, respectively, in the fQRs >90° group and 26.1% and 29.9% in the fQRS ≤90°group. Heart rate, oxygen saturation, fQRS angle, estimated glomerular filtration rate, and C-reactive protein level were predictors of mortality on the multivariable analysis. The mortality risk increased 2.9-fold on the univariate analysis and 1.6-fold on the multivariate analysis for the fQRS >90° patient group versus the fQRS ≤90° group. CONCLUSION: In conclusion, a wide fQRS angle >90° was a predictor of in-hospital mortality and associated with the need for mechanical ventilation among COVID-19 patients.

Fragmented QRS is a marker of mortality in patients with severe COVID-19: A retrospective observational study.

OBJECTIVE: In this study, we aimed to investigate the association of fragmented QRS (f-QRS) with in-hospital death in patients with severe novel coronavirus disease 2019 (COVID-19). METHODS: This was a retrospective and observational study. A total of 201 consecutive patients with severe COVID-19 were enrolled. Demographic data, laboratory parameters, medications, electrocardiographic (ECG) findings, and clinical outcomes were recorded. Patients with and without f-QRS were compared, and predictors of all-cause in-hospital mortality were analyzed. RESULTS: A total of 135 patients without f-QRS (mean age of 64 years, 43% women) and 66 patients with f-QRS (mean age of 66 years, 39% women) were included. C-reactive protein (CRP), D-dimer, troponin I, ferritin levels, and CRP to albumin ratio were significantly higher in patients with f-QRS. The need for invasive mechanical ventilation (63.6% vs. 41.5%, p=0.003) and all-cause in-hospital mortality [54.5% vs. 28.9%, log rank p=0.001, relative risk 1.88, 95% confidence interval (CI) 1.16-4.78] were significantly higher in patients with f-QRS. A number value of f-QRS leads ≥2 yields sensitivity and specificity (85.3% and 86.7%, respectively) for predicting in-hospital all-cause mortality. Multivariable analysis showed that f-QRS (odds ratio: 1.041, 95% Cl: 1.021-1.192, p=0.040) were independently associated with in-hospital death. CONCLUSION: This study revealed that the presence of f-QRS in ECG is associated with higher in-hospital all-cause mortality in patients with severe COVID-19. f-QRS is an easily applicable simple indicator to predict the risk of death in these patients.

Prognostic value of C-reactive protein/albumin ratio in hypertensive COVID-19 patients.

OBJECTIVES: The aim of this study was to investigate the relationship between the C-reactive protein/albumin ratio and the prognosis of hypertensive COVID-19 patients. METHODS: It was designed as a single center retrospective study. PCR positive COVID-19 patients who were followed up in the intensive care unit (ICU) and received antihypertensive treatment were included in the study. The patients were divided into two groups as survivor and non-survivor. C-reactive protein/albumin (CAR) ratios of the patients were compared. The cut-off value was determined as a mortality predictor. The effect of CAR on mortality was evaluated using Logistic Regression analysis. RESULTS: 281 patients were included in the study. Groups consisted of 135 (non-survivor) and 146 (survivor) patients. CAR was significantly higher in the non-survivor group (p<0.001). The area under the ROC curve for CAR for mortality was 0.807, with sensitivity of 0.71 and specificity of 0.71. The cut-off value for CAR was calculated as 56.62. In logistic regression analysis, CAR increases mortality 4.9 times compared to the cut-off value. CONCLUSION: CAR is a powerful and independent prognostic marker for predicting mortality and disease progression in hypertensive COVID-19 patients.

Type 1 Kounis Syndrome Induced by Inactivated SARS-COV-2 Vaccine.

Background Vaccination is the most important way out of the novel coronavirus disease 2019 (COVID-19) pandemic. Vaccination practices have started in different countries for community immunity. In this process, health authorities in different countries have preferred different type of COVID-19 vaccines. Inactivated COVID-19 vaccine is one of these options and has been administered to more than 7 million people in Turkey. Inactivated vaccines are generally considered safe. Kounis syndrome (KS) is a rare clinical condition defined as the co-existence of acute coronary syndromes and allergic reactions. Case Report We present the case of a 41-year-old woman with no cardiovascular risk factors who was admitted at our emergency department with flushing, palpitation, dyspnea, and chest pain 15 min after the first dose of inactivated CoronaVac (Sinovac Life Sciences, Beijing, China). Electrocardiogram (ECG) showed V4-6 T wave inversion, and echocardiography revealed left ventricular wall motion abnormalities. Troponin-I level on arrival was elevated. Coronary angiography showed no sign of coronary atherosclerosis. She was diagnosed with type 1 KS. The patient's symptoms resolved and she was discharged from hospital in a good condition. Why Should an Emergency Physician Be Aware of This? To the best of our knowledge, this is the first case of allergic myocardial infarction secondary to inactivated coronavirus vaccine. This case demonstrates that KS can occur after inactivated virus vaccine against COVID-19. Although the risk of severe allergic reaction after administration of CoronaVac seems to be very low, people who developed chest pain after vaccine administration should be followed by ECG and troponin measurements.

CHA2DS2-VASc score and modified CHA2DS2-VASc score can predict mortality and intensive care unit hospitalization in COVID-19 patients.

In this study, we investigated whether the CHA2DS2-VASc score could be used to estimate the need for hospitalization in the intensive care unit (ICU), the length of stay in the ICU, and mortality in patients with COVID-19. Patients admitted to Merkezefendi State Hospital because of COVID-19 diagnosis confirmed by RNA detection of virus by using polymerase chain reaction between March 24, 2020 and July 6, 2020, were screened retrospectively. The CHA2DS2-VASc and modified CHA2DS2-VASc score of all patients was calculated. Also, we received all patients' complete biochemical markers including D-dimer, Troponin I, and c-reactive protein on admission. We enrolled 1000 patients; 791 were admitted to the general medical service and 209 to the ICU; 82 of these 209 patients died. The ROC curves of the CHA2DS2-VASc and M-CHA2DS2-VASc scores were analyzed. The cut-off values of these scores for predicting mortality were ≥ 3 (2 or under and 3). The CHA2DS2-VASc and M-CHA2DS2-VASc scores had an area under the curve value of 0.89 on the ROC. The sensitivity and specificity of the CHA2DS2-VASc scores were 81.7% and 83.8%, respectively; the sensitivity and specificity of the M-CHA2DS2-VASc scores were 85.3% and 84.1%, respectively. Multivariate logistic regression analysis showed that CHA2DS2-VASc, Troponin I, D-Dimer, and CRP were independent predictors of mortality in COVID-19 patients. Using a simple and easily available scoring system, CHA2DS2-VASc and M-CHA2DS2-VASc scores can be assessed in patients diagnosed with COVID-19. These scores can predict mortality and the need for ICU hospitalization in these patients.

Hydroxychloroquine/azithromycin treatment, QT interval and ventricular arrhythmias in hospitalised patients with COVID-19.

BACKGROUND: Hydroxychloroquine (HCQ) and azithromycin (AZM) are widely used in off-label treatment of novel coronavirus disease (COVID-19). However, cardiac safety of these drugs is still controversial in COVID-19. Therefore, we aimed to evaluate association of HCQ or HCQ + AZM treatment regimens, corrected QT (QTc) interval and malignant ventricular arrhythmias in hospitalized patients. METHODS: This is a single-center, retrospective and observational study. All data were extracted from the electronic medical records. The initial and post-treatment mean QTc intervals were calculated and compared in patients with HCQ alone or HCQ + AZM therapy. Associated factors with QTc prolongation, the incidence of ventricular arrhythmia during treatment and in-hospital mortality because of ventricular arrhythmias were evaluated. RESULTS: Our cohort comprised 101 hospitalized COVID-19 patients (mean age of 49.60 ± 18 years, 54.4% men). HCQ + AZM combination therapy group (n = 56) was more likely to have comorbidities. After 5-days treatment, 19 (18.8%) patients had QTc prolongation, and significant increase in the QTc interval was observed in both two groups (P < .001). However, HCQ + AZM combination group had significantly higher ΔQTc compared to HCQ group (22.5 ± 18.4 vs 7.5 ± 15.3 ms, P < .001). All of 101 patients completed the 5-days treatment without interruption. Also, no malignant ventricular arrhythmia or death secondary to ventricular arrhythmia occurred during the treatment in both groups. CONCLUSIONS: The present study revealed that although HCQ + AZM treatment was independently associated with QTc prolongation, none of patients experienced malignant ventricular arrhythmia or death during treatment. Further prospective studies are needed to determine the exact implications of these drugs on arrhythmias in patients with COVID-19.

The effect of transcatheter aortic valve implantation on mean platelet volume.

BACKGROUND/AIM: Transcatheter aortic valve implantation (TAVI) is an innovative approach to the treatment of aortic stenosis (AS) as an alternative to surgery in high-risk patients. Mean platelet volume (MPV) is considered an indicator of endothelial dysfunction, platelet function, and activation. In this study, we aimed to investigate MPV changes in patients undergoing TAVI. MATERIALS AND METHODS: This study included 100 patients diagnosed with symptomatic severe AS and treated with TAVI between July 2011 and August 2013. Hematological parameters of the patients were examined prior to the procedure and 24 h, 1 month, and 6 months after TAVI. RESULTS: A statistically significant change in patients' MPV was detected after TAVI compared to the baseline situation (P: 0.001). While no statistically significant change was observed on the first day after TAVI, at discharge, compared to the baseline situation, a statistically significant decrease was seen 1 month and 6 months after discharge. CONCLUSION: We have demonstrated a decrease in MPV after surgery compared to the value before surgery. We have sought to propound the change in MPV as an indication of endothelial function after TAVI.

Prosthetic valve endocarditis 7 months after transcatheter aortic valve implantation diagnosed with 3D TEE.

Transcatheter aortic valve implantation (TAVI) was introduced as an alternative treatment for patients with severe symptomatic aortic stenosis for whom surgery would be high-risk. Prosthetic aortic valve endocarditis is a serious complication of surgical AVR (SAVR) with high morbidity and mortality. According to recent cases, post-TAVI prosthetic valve endocarditis (PVE) seems to occur very rarely. We present the case of a 75-year-old woman who underwent TAVI (Edwards Saphien XT) with an uneventful postoperative stay. She was diagnosed with endocarditis using three dimensional (3D) echocardiography on the TAVI device 7 months later and she subsequently underwent surgical aortic valve replacement. Little experience of the interpretation of transoesophageal echocardiography (TEE) and the clinical course and effectiveness of treatment strategies in post-TAVI endocarditis exists. We report a case of PVE in a TAVI patient which was diagnosed with three-dimensional transoesophageal echocardiography (3DTEE).

Transcatheter aortic valve implantation in the presence of hematologic malignancies.

OBJECTIVE: Cardiac surgery may be performed in patients with hematologic disorders, but carries an increased risk of morbidity. This series describes an experience of transcatheter aortic valve implantation (TAVI) in patients with hematologic malignancies, and highlights the technical considerations to be kept in mind. METHODS: Between June 2011 and April 2014, 133 consecutive high-risk patients with symptomatic severe aortic stenosis were treated with TAVI at our centre. Based on consensus among the local heart team, five patients with hematologic malignancies (myelodysplastic syndrome [2],chronic lymphocytic leukemia [2], Hodgkin lymphoma [1]) were considered high risk for surgery (Logistic EUROSCORE 17.2±14.0% and STS score 5.8±4.3%). Serial echocardiographic and clinical follow-ups were done pre- and post-procedure, at discharge, and at 1, 3, 6 and 12 months. RESULTS: Our procedural success rate was 80%. Two heart valves were implanted in one patient due to aortic embolization of the previous valve. Perforation of the right ventricle and cardiac tamponade occurred in the same patient. Mean blood transfusion requirement was 1.0±1.4 U (range: 0 to 3 U). Mean aortic valve gradient was reduced from baseline to 9.2±3.27 mmHg, and the effective orifice area was significantly increased to 1.96±0.29 cm2. Paravalvular aortic regurgitation (AR) was absent-mild in all the patients. CONCLUSION: This present series demonstrates that TAVI with a balloon-expandable valve can be performed safely and effectively and is technically feasible in high-risk patients with hematologic malignancies.

Successful transcatheter aortic valve implantation in a Hodgkin lymphoma patient with severe aortic stenosis.

Transcatheter aortic valve implantation (TAVI) has emerged as an acceptable treatment modality for patients with severe aortic stenosis (AS) who are deemed unsuitable for conventional surgical aortic valve replacement. TAVI not only provides the treatment of AS, but also makes some other diseases treatable by relieving hemodynamic distress resulting from AS. In this case report, we presented a 74-year-old patient with Hodgkin's lymphoma (HL) that had been left untreated due to the development of acute pulmonary edema caused by severe degenerative AS during chemotherapy. This is the first report of the use of TAVI in a patient with HL.