Infective endocarditis after transcatheter approach versus surgical pulmonary valve replacement: A meta-analysis.

Background: In this meta-analysis, we aimed to assess the risk of infective endocarditis in transcatheter versus surgical pulmonary valve replacement patients. Methods: We systematically searched PubMed, Cochrane, EMBASE, Scopus, and Web of Science for the studies that reported the event rate of infective endocarditis in both transcatheter and surgical pulmonary valve replacement between December 2012 and December 2021. Random-effects model was used in the meta-analysis. Results: Fifteen comparison groups with 4,706 patients were included. The mean follow-up was 38.5±3.7 months. Patients with transcatheter pulmonary valve replacement had a higher risk of infective endocarditis than patients receiving surgically replaced valves (OR 2.68, 95% CI: 1.83-3.93, p<0.00001). The calculated absolute risk difference was 0.03 (95% CI: 0.01-0.05), indicating that if 1,000 patients received a surgical valve replacement, 30 cases of infective endocarditis would be prevented. A meta-regression of follow-up time on the incidence of infective endocarditis was not statistically significant (p=0.753). Conclusion: Although transcatheter pulmonary valve replacement is a feasible alternative to surgical replacement in severe right ventricular outflow tract dysfunction, the higher incidence of infective endocarditis in transcatheter replacement remains a significant concern. Regarding this analysis, surgical treatment of right ventricular outflow tract dysfunction is still a viable option in patients with prohibitive risk.

Transcatheter Tricuspid Valve Replacement for Tricuspid Regurgitation: A Systematic Review and Meta-analysis.

BACKGROUND: The present data aim to evaluate the feasibility of the orthotopic trans- catheter tricuspid valve replacement devices, echocardiographic, functional improve- ments, and mortality rates following replacement in patients with significant tricuspid valve regurgitation. METHODS: We systematically searched for the studies evaluating the efficacy and safety of transcatheter tricuspid valve replacement for significant tricuspid valve regurgitation. The efficacy and safety outcomes were the improvements in New York Heart Association functional class, 6-minute walking distance, all-cause death, and periprocedural andlong-term complications. In addition, a random-effect meta-analysis was performed comparing outcomes before and after transcatheter tricuspid valve replacement. RESULTS: Nine studies with 321 patients were included. The mean age was 75.8 years, and the mean European System for Cardiac Operative Risk Evaluation II score was 8.2% (95% CI: 6.1 to 10.3). Severe, massive, and torrential tricuspid valve regurgitation was diagnosed in 95% of patients (95% CI: 89% to 98%), and 83% (95% CI: 73% to 90%) of patients were in New York Heart Association functional class III or IV. At a weighted mean follow-up of 122 days, New York Heart Association functional class (risk ratio = 0.20; 95% CI: 0.11 to 0.35; P < .001) and 6-minute walking distance (mean difference = 91.1 m; 95% CI: 37.3 to 144.9 m; P < .001) significantly improved, and similarly, the prevalence of severe or greater tri- cuspid valve regurgitation was significantly reduced after transcatheter tricuspid valve replacement (baseline risk ratio = 0.19; 95% CI: 0.10 to 0.36; P < .001). In total, 28 patients (10%; 95% CI: 6% to 17%) had died. Pooled analyses demonstrated non-significant differ- ences in hospital and 30-day mortality and >30-day mortality than predicted operative mortality (risk ratio = 1.03; 95% CI: 0.41 to 2.59; P = .95, risk ratio = 1.39; 95% CI: 0.69 to 2.81; P = .35, respectively). CONCLUSION: Transcatheter tricuspid valve replacement could be an emerging treatment option for patients with severe tricuspid regurgitation who are not eligible for transcath-eter repair or surgical replacement because of high surgical risk and poor prognosis.

Abnormal Dispersion of Ventricular Repolarization as a Risk Factor in Patients with Human Immunodeficiency Virus: Tp-e Interval, Tp-e/QTc Ratio.

OBJECTIVE: In recent years, there has been worldwide recognition of the problems associated with Human Immunodeficiency Virus (HIV) infection and Acquired Immune Deficiency Syndrome (AIDS). The prevalence of cardiovascular disease in the HIV-infected population is increasing. Repolarization abnormalities, the significant contributor to life-threatening arrhythmias and mortality, are the most frequent electrocardiographic changes in this population. This study aimed to evaluate the changes in Tp-e interval, Tp-e/QT and Tp-e/corrected QT (QTc) ratios, and traditional electrocardiographic features of electrical dispersion in adults infected with HIV. SUBJECTS AND METHODS: A total of 235 participants were selected in the current study. The HIV group consisted of 85 subjects (median age 36 years [25-48], and the control group included 150 individuals (median age 39 years [27-51]). Tp-e interval, Tp-e/QT and Tp-e/QTc ratios were measured by the 12-lead electrocardiogram. RESULTS: Tp-e interval, cTp-e interval, and Tp-e/QT and Tp-e/QTc ratios were significantly higher in HIV patients compared to the control group (p = 0.006, p = 0.004, p = 0.003, and p = 0.002, respectively). In correlation analysis, there was inverse correlation between the mean cTp-e interval and CD4 count and Tp-e/QTc ratios and CD4 count (r = - 0.407, p < 0.001, r = - 0.416, p < 0.001, respectively). Besides, there was correlation between the mean cTp-e interval and high-sensitivity C-reactive protein (hsCRP) and Tp-e/QTc ratios and hsCRP (r = 0.403, p = 0.001, r = 0.406, p = 0.001, respectively). CONCLUSION: Our study revealed that the cTp-e interval, Tp-e/QT and cTp-e/QT ratios were prolonged and correlated to the severity of the disease in HIV-infected patients. Our findings may shed light on the cTp-e interval and Tp-e/QTc ratio and lead to further studies showing a relationship with ventricular arrhythmias and mortality in HIV-infected individuals.

Whole blood viscosity in microvascular angina and coronary artery disease: Significance and utility.

INTRODUCTION AND OBJECTIVES: Whole blood viscosity (WBV) is the intrinsic resistance of blood flow in vessels, and when elevated induces endothelial shear stress and endothelial inflammation and can accelerate the atherosclerotic process. This study aims to compare WBV levels in patients with microvascular angina (MVA), patients with coronary artery disease (CAD), and normal controls, and to identify the relationship between WBV and high-sensitivity C-reactive protein as a marker of inflammation in MVA and CAD. METHODS: A total of 573 patients were studied. The MVA group consisted of 189 subjects, the CAD group consisted of 203 subjects, and the control group consisted of 181 age- and gender-matched individuals. WBV was calculated from hematocrit and plasma protein concentration at a low shear rate (0.5 s-1) and high shear rate (208 s-1) by a validated equation. RESULTS: Patients with CAD and MVA had significantly higher WBV at both low and high shear rates compared to the control group. Correlation analysis revealed a significant relationship between high-sensitivity C-reactive protein and WBV at low (r=0.556; p<0.001) and high shear rates (r=0.562) in the CAD group and at low (r=0.475) and high shear rates (r=0.493) in the MVA group. CONCLUSIONS: Overall, this study demonstrated a significant and independent association between blood viscosity and the existence of endothelial inflammation and the atherosclerotic process.

Prognostic Significance of Heart Rate Turbulence Parameters in Patients with Noncompaction Cardiomyopathy.

BACKGROUND: Noncompaction cardiomyopathy (NC) is a rare congenital heart disease characterized by progressive heart failure and life-threatening arrhythmias. Heart rate turbulence (HRT) has been defined as a noninvasive prognostic method to reveal the cardiac death risk in high-risk patients. OBJECTIVES: We aimed to assess the cardiac autonomic functions and their relations to the mortality in NC patients. METHODS: A total of 60 NC patients and 70 healthy controls were included in this study. All participants underwent 24-h Holter recording to assess the HRT parameters, included turbulence onset (TO), turbulence slope (TS), standard deviation of NN intervals of all normal beats (SDNN) and mean RR interval. RESULTS: NC patients had higher levels of TO than the control group (0.43 ± 4.66% vs. -1.82 ± 2.19%, p = 0.024), but the TS levels of NC patients were lower than those of the control group (3.43 ± 3.28 vs. 4.94 ± 2.86 ms/RR, p = 0.024). Thirteen patients died during follow-up (mean 83.3 ± 32.5 months). TS was the strongest univariate mortality predictor (hazard ratio 10.01 [95% CI 2.22-42.52]; p = 0.004) in univariate Cox regression analysis. In multivariate analysis, LVEF ≤0.40 and TS ≤2.5 ms/RR interval were the only independent predictors of mortality (hazard ratio 5.29; p = 0.004, hazard ratio 13.45; p = 0.001, respectively). CONCLUSIONS: Patients with NC showed abnormal HRV and HRT parameters when compared to healthy subjects. Furthermore, impaired HRT reaction in NC is an independent predictor of mortality.

Effects of Direct Oral Anticoagulants on Quality of Life During Periprocedural Management for Dental Extractions.

PURPOSE: Direct oral anticoagulants (DOACs) have many advantages over warfarin regarding periprocedural management for dental extractions. They avoid the need to assess and possibly adjust warfarin therapy to achieve appropriate hemostatic status before and after extraction. The present study evaluated the real-life data regarding quality of life (QoL) and burden for patients with atrial fibrillation receiving long-term treatment with warfarin or DOACs during periprocedural management for dental extraction. PATIENTS AND METHODS: We implemented a multicenter study. The sample was composed of 205 patients who had been receiving long-term anticoagulation treatment with warfarin (n = 133) or DOACs (n = 72). The Duke Anticoagulation Satisfaction Scale (DASS) was used to assess the QoL. Periprocedural management for dental extraction was recorded using the questions designed by us. RESULTS: Warfarin created a significantly greater burden for patients during periprocedural management for dental extraction compared with DOACs. The DASS results showed that the QoL of patients was significantly better for the DOAC group than for the warfarin group (score, 75.19 ± 18.52 and 90.12 ± 17.28, respectively; P = .0001). Of the patients in the DOAC group, 45 had used warfarin as their previous therapy and had undergone another tooth extraction while using warfarin. Of these patients, 91.1% chose DOACs as their anticoagulant of choice for dental extraction. CONCLUSION: The present findings suggest that DOACs have many advantages compared with warfarin regarding the reported QoL and periprocedural management of dental extraction.

Level of Anxiety and Depression in Cardiac Syndrome X.

OBJECTIVE: Cardiac syndrome X (CSX) is defined as angina-like symptoms, abnormalities on stress testing, and normal epicardial coronary arteries on coronary angiography. The aim of this study was to determine the Hospital Anxiety and Depression scores of patients with CSX and to compare with healthy controls. Materials/Subjects and Methods: Patients undergoing coronary angiography between January 2015 and December 2016 because of clinical indications, including abnormal noninvasive test results were examined. Two hundred and 10 subjects (110 patients with CSX, 100 controls) were enrolled. Demographic characteristics including age, education level, marriage status, and history of stressful life events were recorded. The Turkish version of the Hospital Anxiety and Depression scale was evaluated in the study population. RESULTS: Anxiety, depression, and total scores in the patients with CSX were significantly higher than those in the control group (p < 0.001, p < 0.003, p < 0.001, respectively). Among women, anxiety, depression, total scores, and stressful life events were significantly higher in the CSX group (p = 0.006, p = 0.015, p = 0.001, p < 0.001, respectively). Patients with lower educational status had higher anxiety scores (p = 0.03), stressful life events, and HAD-A > 10 were the only independent predictors of CSX in logistic regression analysis with comparable ORs 2.256 (95% CI 1.057-4.817, p = 0.03) and 2,399 (95% CI 1.248-4.613, p = 0.009) respectively. CONCLUSION: The results of our research suggest that patients with CSX have a high prevalence of stress and psychiatric disturbances. Interventions targeted toward improving the quality of life and to give psychological support may have the potential benefits especially for women and individuals with lower education.

Can abnormal dispersion of ventricular repolarization be a predictor of mortality in arrhythmogenic right ventricular cardiomyopathy: The importance of Tp-e interval.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by ventricular arrhythmias and specific ventricular pathology. Repolarization abnormalities, the significant contributor to life-threatening arrhythmias and mortality, are frequently observed ECG changes in patients with ARVC. This study aimed to evaluate the changes in Tp-e interval, Tp-e/QT, Tp-e/QTc ratio, and traditional electrocardiographic features of electrical dispersion in patients with ARVC. METHODS: A total of 105 participants were enrolled in the current study. The ARVC group consisted of 40 subjects (30 men, with a median of 35 (26-41) years), and the control group included of 65 age and sex-matched individuals (42 men, with a median of 37 (24-45) years). The Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were measured by the 12-lead electrocardiogram. RESULTS: Tp-e interval, cTp-e interval, Tp-e/QT, and Tp-e/QTc ratio were significantly higher in ARVC patients compared to the control group (all p < 0.001). Tp-e interval, cTp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were significantly increased in deceased ARVC patients compared to the survival group (p = 0.038, p < 0.001, p = 0.006, p = 0.032, respectively). In the multivariate analysis, RV-FAC and cTp-e interval level (p < 0.05 for each parameter) were associated with all-cause mortality [odds ratio 1.747 95% CI (1.012-3.018); p = 0.045 and odds ratio 1.166, 95% CI (1.017-1.336); p = 0.027, respectively]. CONCLUSION: Tp-e interval, cTp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were prolonged in patients with NC. We revealed that abnormal dispersion of ventricular repolarization suggests the increased risk of mortality in ARVC.

The Prevalence and Risks of Inappropriate Combination of Aspirin and Warfarin in Clinical Practice: Results From WARFARIN-TR Study

Background: The use of warfarin and aspirin in combination is restricted to limited patients under relevant guidelines. Aims: To evaluate the prevalence of the inappropriate combination of aspirin and warfarin therapy in daily practice and its risks. Study Design: Cross-sectional study. Methods: The awareness, efficacy, safety, and time in the therapeutic range of warfarin in the Turkish population study is a multi-center observational study that includes 4987 patients using warfarin for any reason between January 1, 2014, and December 31, 2014. To determine the prevalence of inappropriate combination use in daily practice, all patients who had a history of atherosclerotic disease (ischemic heart disease, peripheral artery disease) or cerebrovascular disease (n=1498) were excluded. The data of 3489 patients were analyzed. We defined inappropriate combination as all patients who received aspirin and warfarin regardless of the indication for warfarin use, under the direction of the European Society of Cardiology guideline recommendation. Results: The mean age of patients was 59.2±13.8 years (41.8% male). The prevalence of the inappropriate use of warfarin and aspirin combination was 20.0%. The prevalence of combination therapy in patients with a primary indication for mechanical heart valve, non-valvular atrial fibrillation, and other reasons was 20.5%, 18.7%, and 21.0%, respectively. Multivariate logistic regression analysis revealed that age (odds ratio, 1.009; 95% confidence interval, 1.002-1.015; p=0.010), heart failure (odds ratio, 1.765; 95% confidence interval, 1.448-2.151; p<0.001), smoking (odds ratio, 1.762; 95% confidence interval, 1.441-1.153; p<0.010), chronic kidney disease (odds ratio, 2.057; 95% confidence interval, 1.494-2.833; p<0.001), and deep vein thrombosis (odds ratio, 0.463; 95% confidence interval, 0.229-0.718; p=0.001) were independent predictors of combination therapy (r2=0.66). The mean time in therapeutic range of patients receiving combination therapy was significantly lower than in those on warfarin monotherapy (51.6±27.05 vs. 54.7±23.93; p=0.006). Overall, 19.4% (n=677) of patients had a bleeding event (major bleeding 13.0%, n=88) within a year. Percentages of patients with combination therapy were significantly higher in patients with major bleeding than in patients without major bleeding (29.5% vs. 19.7%; p=0.023). Conclusion: Our study demonstrated that 20.0% of patients taking warfarin use concomitant aspirin inappropriately in daily practice. Patients receiving aspirin with warfarin were demonstrated to have more comorbidities, lower time in therapeutic range levels, and higher bleeding rates.

Essential parameters and risk factors of the patients for diabetes care and treatment.

AIM: The aim was to explore the association between Type 2 Diabetes Mellitus [T2DM] treatment satisfactions of patients regarding their socio-economic, life-style, history medication and clinical outcome in a Turkish population SUBJECT AND METHODS: A cross-sectional study conducted from February 2016 to September 2016. Of the total 1500 diabetic patients approached, 1094 (72.9%) gave their consent. Data analysis included, sociodemographic, serum lipid profiles (LDL, HDL), calcium, uric acid, blood pressure and glycated hemoglobin (HbA1c) at baseline and after six months. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) tools were used to measure the patient satisfaction. RESULTS: The mean and standard deviation of age among gender, there were significant differences between males (51.81±14.40) and females (49.76±13.99) (p=0.024). There were statistically significant differences between males and females regarding place of living (city 76% vs town 26%) p<0.001) and consanguinity (p=0.040). Almost of the patients with diabetes were overweight (males 44.5% vs females 41.8%) while more than a quarter (31.2%) males were obese. Among patients with diabetes, significantly larger proportion were treated for DM with insulin (females 28.8% vs males 22.5%) and 'insulin & oral anti diabetic drugs' (females 21.6% vs males 18.4%%; p<0.001) in comparison. Reported average sleeping haours was significantly more among males (6.5±1.1 vs. 6.1±1.2; p<0.001) than females. Males and females reported significantly greater improvements in mean values of blood glucose (-2.07 p<0.001; vs. -2.36; p=0.007), HbA1c (-1.72 p<0.001; vs. -1.47 p=0.038), potassium (+0.98 p<0.001; vs. +0.93 p<0.005); albumin (-3.38 p<0.001; vs. -3.60; p<0.001); billirubin (-0.69 p=0.049; vs. -0.98; p<0.001); uric acid (+11.9 p=0.017; vs. +14.3; p<0.001); systolic blood pressure (-3.86 p<0.001; vs. -3.2 p<0.001) and diastolic blood pressure (-3.17 p<0.001; vs. -3.2 p<0.001) in comparison to 6 months before. Multivariate stepwise regression analysis showed that the satisfaction DTSQ scores for HbA1c (p<0.001), h of sleep (p<0.001), neuropathy (p=0.007), diabetic education (p=0.014), SBP (mmHg) (p=0.021) DBP (mmHg) (p=0.028) were identified as significantly associated with higher treatment satisfaction. CONCLUSION: The study confirms a positive correlation between diabetes patient's satisfaction with care and treatment. Females DM patients compared to males had a better satisfaction score with current treatment, unacceptably low blood glucose level, flexibility in treatment and understanding of DM.

A case of Mobitz type II atrioventricular block due to Nerium oleander poisoning successfully managed with digoxin-specific Fab antibody fragments.

Nerium oleander is a popular ornamental plant grown in many tropical and subtropical countries and in the Mediterranean region. It is dangerous because it has been shown to contain several types of cardiac glycosides, and hence can cause cardiac arrhythmias resembling digoxin in their toxicologic manifestations. We report a patient presenting to our hospital with Mobitz type II atrioventricular block after drinking herbal tea prepared from oleander leaves. Three hours after admission, a 200-mg empiric dose of digoxin-specific Fab antibody fragments was administered intravenously over 30 minutes. A 12-lead electrocardiogram (ECG) revealed sinus rhythm at the end of infusion. After 72 hours, the patient was discharged without any symptoms.

Jet length/velocity ratio: a new index for echocardiographic evaluation of chronic aortic regurgitation.

BACKGROUND: Management of aortic regurgitation depends on the assessment for severity. Echocardiography remains as the most widely available tool for evaluation of aortic regurgitation. In this manuscript, we describe a novel parameter, jet length/velocity ratio, for the diagnosis of severe aortic regurgitation. METHODS AND RESULTS: A total of 30 patients with aortic regurgitation were included to this study. Severity of aortic regurgitation was assessed with an aortic regurgitation index incorporating five echocardiographic parameters. Jet length/velocity ratio is calculated as the ratio of maximum jet penetrance to mean velocity of regurgitant flow. Jet length/velocity ratio was significantly higher in patients with severe aortic regurgitation (2.03 ± 0.53) compared to patients with less than severe aortic regurgitation (1.24 ± 0.32, P < 0.001). Correlation of jet length/velocity ratio with aortic regurgitation index was very good (r(2) = 0.86) and correlation coefficient was higher for jet length/velocity ratio compared to vena contracta, jet width/LVOT ratio and pressure half time. For a cutoff value of 1.61, jet length/velocity ratio had a sensitivity of 92% and specificity of 88%, with an AUC value of 0.955. CONCLUSIONS: Jet length/velocity ratio is a novel parameter that can be used to assess severity of chronic aortic regurgitation. Main limitation for usage of this novel parameter is jet impringement to left ventricular wall.

The independent association of plateletcrit with long-term outcomes in patients undergoing primary percutaneous coronary intervention.

PURPOSE: Platelets play a key role in the genesis of thrombosis. Plateletcrit (PCT) provides complete information on total platelet mass. The relationship between PCT values and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary angioplasty is not known. We sought to determine the effect of PCT values on the outcomes of primary angioplasty for STEMI. METHODS: Overall, 2572 consecutive STEMI patients (mean age, 56.6±11.8 years) undergoing primary percutaneous coronary intervention were enrolled retrospectively into the present study. Plateletcrit at admission was measured as part of the automated complete blood count. Patients were classified into 2 groups: high PCT (>0.237, n=852) and nonhigh PCT (<0.237, n=1720). Clinical characteristics and in-hospital and long-term (median, 21 months) outcomes of primary angioplasty were analyzed. RESULTS: A higher in-hospital shock rate was observed among patients with high PCT values compared with those with nonhigh PCT values (6.5 vs 3.8%, respectively; P=.003). The long-term cardiovascular prognosis was worse for patients with high PCT values (Kaplan-Meier, log-rank test; P=.007). We used Cox proportional hazard models to examine the association between PCT and adverse clinical outcomes. High PCT values were also an independent predictor of cardiovascular mortality (hazard ratio, 1.85; 95% confidence interval, 1.061-3.22; P=.03). CONCLUSION: High PCT values on admission are independently associated with long-term adverse outcomes in patients with STEMI who undergo primary angioplasty.

Can the T-peak to T-end interval be a predictor of mortality in patients with ST-elevation myocardial infarction?

BACKGROUND: The interval between the peak and the end of the T wave (Tp-e interval) on 12-lead ECG is a measure of transmural dispersion of repolarization and may be related to malignant ventricular arrhythmias. The objective of this study was to investigate whether the Tp-e interval predicts in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (pPCI). METHODS: This study included 488 consecutive patients with STEMI treated with pPCI. Electrocardiograms were obtained after pPCI and the Tp-e interval was measured in leads without ST-segment elevation. RESULTS: There were 46 (9.4%) deaths in the population, with a mean follow-up time of 21.1±10.2 months. The Tp-e interval was associated with not only in-hospital ventricular tachycardia/fibrillation, target vessel revascularization, and death but also long-term target vessel revascularization and death. Furthermore, the Tp-e interval measured using the tail method was found to be a significant predictor of long-term mortality in multivariable Cox analyses [odds ratio 1.018, 95% confidence interval (1.004-1.033)]. Findings were similar in the Tp-e interval and the heart rate-corrected Tp-e interval (cTp-e). CONCLUSION: Tp-e and cTp-e measured using the tail method were found to be predictors of both in-hospital and long-term mortality.