Successful percutaneous intervention to acute myocardial infarction presenting with typical chest pain in transplanted heart.

Allograft coronary artery disease (CAD) is the main limiting factor of the long-term survival in cardiac transplant recipients. It is present in approximately 50% of patients at 5 years post-transplant. Allograft CAD might result in congestive heart failure, ventricular arrhythmias and sudden cardiac death. Acute coronary syndrome is a rare presentation of allograft CAD, because symptoms are usually atypical or absent as a result of cardiac denervation. However, it should be reminded that reinnervation of the transplanted heart might occur, and angina pectoris could be felt as a sign of an acute coronary syndrome. We present a 27-year-old female cardiac transplant patient with an acute myocardial infarction, who was successfully treated with percutaneous transluminal coronary angioplasty.

The effects of perindopril on aortic elasticity and inflammatory markers in hypertensive patients.

BACKGROUND: Inflammation plays an important role in hypertension and in atherosclerosis. Inflammatory changes induced even in prehypertensive subjects can lead to increased arterial stiffness. The effects of perindopril on both inflammatory and aortic elasticity markers were tested in hypertensive patients. MATERIAL/METHODS: One hundred nine hypertensive patients not taking any antihypertensive therapy were included in the study. Aortic strain, aortic distensibility, aortic stiffness index, and inflammatory markers, including CRP, IL-1alpha IL-1beta, and TNF-alpha, were measured in all patients before and after twenty weeks of perindopril therapy. RESULTS: While aortic strain and distensibility showed statistically significant increases with perindopril therapy, the aortic stiffness index and inflammatory markers were found to decrease. CONCLUSIONS: Perindopril therapy resulted in an improvement in aortic elastic properties. There was also an attenuation of inflammatory status of the patients as reflected by lower inflammatory marker levels compared with pretreatment values.

Left atrial appendage can still cause clinical events after ligation.

We present a 71-year-old female patient with transient ischaemic attack. A thrombus located at the stump of previously ligated left atrial appendage was suspected as the cause of event.

Echocardiographic, electrocardiographic, and clinical correlates of recurrent transient ischemic attacks: a follow-up study.

BACKGROUND: Transient ischemic attack (TIA) is presumed to be of cardiovascular origin. The aim of the study was to evaluate the electrocardiographic, echocardiographic, and clinical signs for predicting TIA recurrence. METHODS: A total of 100 consecutive patients presenting with a first episode of TIA without atrial fibrillation, previous stroke, and uncontrolled diabetes or hypertension were enrolled in the study. The electrocardiographic, echocardiographic, and clinical parameters were obtained in those patients. The patients received a follow-up of bimonthly visits and were grouped according to the presence (or lack) of TIA recurrence in the follow-up period. RESULTS: Of these patients, 23 experienced recurrent TIA and 72 did not; 5 patients dropped out. Independent risk factors evaluated for TIA recurrence were aortic diameter, left atrial diameter, P-wave dispersion, hyperlipidemia, absence of lipid lowering, and warfarin treatment. CONCLUSION: Careful electrocardiographic and echocardiographic evaluation of patients with TIA may help assess the outcome of patients and guide therapeutic interventions.

Conventional and non-conventional coronary risk factors in male premature coronary artery disease patients already having a low Framingham risk score.

BACKGROUND: Individual risk factors and, more importantly, global risk assessment tools such as the Framingham risk score have been used successfully for risk prediction especially in older patients. However, there is paucity of data about the coronary heart disease prediction in premature coronary artery disease patients with a low Framingham risk score. METHODS AND RESULTS: We recruited 102 consecutive young patients without hypertension and diabetes mellitus in the study. All subjects had had chest pain and underwent coronary angiography since non-invasive diagnostic test results suggested ischaemia. Forty-five patients having at least one coronary lesion independent of severity were included in the study group.The remaining fifty-seven subjects without any coronary lesion were used as control group. Conventional and non-conventional risk factors were evaluated both in patients and control subjects. Framingham risk score and absolute 10-year hard CHD events risk were also calculated for each individual. The coronary heart disease group had a significantly higher smoking frequency as compared to the control group.They also had higher plasma levels of triglycerides, apolipoprotein B and apo B/AI ratio but a smaller LDL particle size.We failed to find any independent CHD predictor after logistic regression analysis. However, individual ROC curve analysis of risk factors revealed that apolipoprotein B, triglycerides and apo B/AI ratio have the highest area under the curve for coronary artery disease prediction. CONCLUSIONS: The Framingham risk score may underestimate the true risk of an individual. Incorporating non-conventional risk factors such as apolipoprotein B and apo B/apo AI ratio may provide valuable information in these patients.

Unoperated tetralogy of Fallot in a 68-year-old patient.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, generally treated with total correction within the first two years of life. Occasionally, some unoperated cases can reach older ages. A 68-year-old woman with diabetes mellitus presented with swelling in legs and abdomen, weakness, exertional dyspnea, and orthopnea. On physical examination, she had mild cyanosis with clubbing. Her blood pressure was 110/60 mmHg and pulse rate was 79 beat/min. She had a systolic ejection murmur and bilateral rales on basal lung areas. Massive edema was noted in both lower limbs. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest radiography showed an increased cardiothoracic ratio and bilateral minimal pleural effusion. Echocardiography showed biatrial dilatation (right atrium 62 mm, left atrium 49 mm) and thickening of left ventricular walls. There was right ventricular hypertrophy with decreased systolic function. A very large ventricular septal defect and severe pulmonary stenosis were noted. The patient did not accept any interventional procedure. To our knowledge, this is the oldest unoperated TOF case reported from our country.

[Obstruction of the left ventricular outflow tract caused by bicuspid aortic valve and discrete subaortic membrane]. / Biküspid aort kapagi ve diskret subaortik membranin neden oldugu sol ventrikül çikis yolu tikanikligi.

Bicuspid aortic valve is the most common congenital cardiac anomaly and it may often coexist with other congenital cardiac anomalies. Its coexistence with discrete subaortic membrane, causing obstruction of the left ventricular outflow tract is very rare. A 21-year-old male patient presented with complaints of exertional dyspnea and dizziness. On transthoracic echocardiography, the parasternal short-axis view showed a bicuspid aortic valve, and parasternal long-axis color Doppler view showed a mosaic pattern in the subaortic region. A more careful examination of the parasternal long-axis views revealed a discrete subaortic membrane. Continuous-wave Doppler flow velocity obtained from the aortic valve was normal; however, a peak gradient of 30 mmHg was observed with the Valsalva maneuver. The fact that there are very few reports on this rare coexistence may be due to failure to recognize discrete subaortic membrane during echocardiographic examination.

[Does accompanying metabolic syndrome contribute to heart dimensions in hypertensive patients?]. / Hipertansiyonlu hastalarda metabolik sendrom varliginin kalp boyutlarina katkisi var midir?

OBJECTIVES: Metabolic syndrome (MetS) is associated with increased risk for cardiovascular events. We evaluated heart dimensions in hypertensive patients with MetS. STUDY DESIGN: The study included 75 hypertensive patients (34 males, 41 females; mean age 51+/-9 years) without coronary artery disease. Patients were evaluated in two groups depending on the presence or absence of MetS. Age- and gender-matched 20 healthy subjects (9 males, 11 females; mean age 50+/-5 years) comprised the control group. The diagnosis of MetS was based on the presence of at least three of five MetS criteria. Hypertension was defined as arterial blood pressure exceeding 140/85 mmHg on three consecutive measurements or the use of antihypertensive drugs. Echocardiographic measurements included interventricular septal thickness, left ventricular internal diameter, posterior wall thickness, aortic diameter, left atrial diameter, relative wall thickness, and left ventricular mass. RESULTS: Metabolic syndrome was present in 32 hypertensive patients (42.7%; 18 males, 14 females). The mean number of MetS criteria was 2.6+/-1.0 in the hypertensive group. Compared to the control group, patients with or without MetS exhibited significantly increased interventricular septum and posterior wall thickness, left atrial diameter, relative wall thickness, and left ventricular mass (p<0.05). The only significant difference between the two patient groups was that MetS was associated with a greater left atrial diameter (p=0.019). Left atrial diameter was correlated with the number of MetS criteria (r=0.51; p<0.001). CONCLUSION: Left ventricular dimensions are not influenced by MetS. Rather than MetS, hypertension is primarily responsible for changes in left ventricular dimensions. However, left atrial enlargement is more prominent in patients with MetS, suggesting that each MetS criterion contributes to left ventricular diastolic dysfunction.

Evaluation of plasma adiponectin levels in young men with coronary artery disease.

OBJECTIVE: In this study, we investigated the relation between plasma adiponectin levels and other risk factors in a young patient population. MATERIAL AND RESULTS: We enrolled consecutively 69 young patients (< 45 years) with coronary artery disease in the study group. he patient enrollment period was between February 2003 and November 2004. The control group consisted of 42 age- and sex-matched healthy subjects. Anthropometric, lipid and other variables including adiponectin, fasting glucose and plasma insulin levels were measured in all subjects. Appropriate statistical analyses were performed to determine the differences between the groups, the relation between adiponectin and other parameters and independent factors that predict CAD. There was a statistically significant difference between the groups in terms of lipid parameters (triglycerides, total cholesterol, HDL and LDL cholesterol). Mean plasma adiponectin levels were significantly lower in the patients (P < 0.05). Among the risk factors adiponectin had a significant negative association with the plasma triglyceride level (P < 0.01). Logistic regression analysis revealed triglycerides and adiponectin as independent predictors of CAD. The areas under the ROC curves of adiponectin and triglycerides were not different (P > 0.05). CONCLUSION: We found a decreased plasma adiponectin level in young male patients with coronary artery disease. It may be a novel marker of atherosclerosis in young men.

Axenfeld-Rieger syndrome associated with truncus arteriosus: a case report.

The aim of this presentation was to report a case with Axenfeld-Rieger syndrome (ARS) associated with truncus arteriosus (TA). We present a 14-year-old boy with ARS in whom the diagnosis was confirmed by ophthalmologic examination and developmental defects of the teeth and facial bones. Echocardiography revealed TA. With this case demonstrating the association between ARS and TA, the range of reported cardiac malformations is enlarged and the importance of cardiologic evaluation is emphasized in patients with ARS.

[The effect of paclitaxel-eluting stents on restenosis]. / Paklitaksel salan stentlerin restenoz üzerine etkisi.

OBJECTIVE: In our study we aimed to investigate the effects of paclitaxel-eluting stent on restenosis. METHODS: Sixteen porcine were randomly assigned to two groups (n=8 per group): control group animals received conventional stent implantation and study group animals -paclitaxel-eluting stent implantation. Both groups were treated with 300 mg acetylsalicylic acid and 75 mg clopidogrel daily. The degree of neointimal proliferation and effect of drug-eluting stent on restenosis were evaluated 6 weeks after by angiography and intravascular ultrasound (IVUS). RESULTS: Angiographic in-stent restenosis was lower in paclitaxel-eluting stent group (12.50 +/- 7.07% versus 41.25 +/- 28.50%, p=0.001). The IVUS data demonstrated that paclitaxel group animals had larger minimal lumen area (8.76 +/- 1.09 mm2 versus 6.23 +/- 3.10 mm2, p=0.028), smaller mean neointimal proliferation area (1.03 +/- 0.75 mm2 versus 3.55 +/- 2.86 mm2, p=0.01) and mean percent stenosis (10.71 +/- 8.10% versus 36.85 +/- 30.93%, p=0.01). CONCLUSION: This study suggests that drug-eluting stents may also have a preventive effect for the in-stent restenosis.

[The value of augmentation index and myocardial performance index obtained from cardiac catheterization pressure recordings in predicting coronary artery disease]. / Kardiyak kateterizasyona ait basinç kayitlarindan elde edilen artirma indeksi ve miyokardiyal performans indeksinin koroner arter hastaligini öngörme degerleri.

OBJECTIVE: The aim of the study was to determine the relation between some parameters, which can be obtained from cardiac catheterization pressure records, and coronary artery disease. METHODS: The study included 65 patients, in whom coronary angiography was performed by the cardiologists of the study. The parameters could be obtained in 40 patients (59+/-6 years; 28 male), and statistical analysis included the data of these patients. From the pressure recordings, myocardial performance index (MPI), isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), ejection time (ET), augmentation wave amplitude (AW), augmentation wave time (AWT) and augmentation index (AI) were measured manually. Coronary artery disease was defined as the presence of any lesion, without regarding the degree of narrowing. The parameters were evaluated with respect to relation with presence of coronary artery disease (Mann-Whitney U test), relation with risk factors for atherosclerosis (Mann-Whitney U test and Chi square test) and capability of predicting coronary artery disease (area under ROC curve, AUC). Statistical significance was set at 0.05. RESULTS: The presence of coronary artery was significantly related to AI, AWT, AW, IVCT and MPI (p<0.001 for all). The most sensitive parameters for coronary artery disease were AI (sensitivity 94%, AUC -0.846, p<0.001) and AW (sensitivity 94%, AUC -0.848, p<0.001), while the most specific one was AWT (specificity 82%, AUC -0.833, p<0.001). The MPI and IVCT were weakly related with risk factors, while IVRT had stronger relation. The parameters of augmentation wave were significantly related with high density lipoprotein cholesterol, whereas the relation with low density lipoprotein cholesterol was weak. CONCLUSION: The parameters, which are obtained from cardiac catheterization pressure recordings, are related with coronary artery disease. They may be useful for predicting future coronary artery disease especially in patients with normal coronary angiogram. It is useful to add these parameters into the reports of coronary angiograms.

Left atrial functions after myocardial infarction.

Acute myocardial infarction results in not only left ventricular but also left atrial dysfunction. Left atrial function is important for optimal filling of the left ventricle. In this study, we aimed at evaluating left atrial functions 6 months after acute myocardial infarction in three different patient groups (thrombolytic therapy, primary percutaneous intervention, or no reperfusion strategies). Between October 2002 and May 2003, 48 patients with ST elevation myocardial infarction who were either administered thrombolytic therapy (group T, n=16), underwent primary angioplasty (group A, n=20), or underwent no reperfusion therapy (group C, n=12) at our unit were enrolled into the study. Echocardiography was performed in these patients 6 months after acute myocardial infarction. Left atrial contractility was assessed by atrial ejection force. Left atrial contribution was assessed by atrial fractional shortening and left atrial volume was calculated. The left atrial volume was significantly higher in group C (P<0.05), but there was no significant difference between groups A and T (P>0.05). Patients in group C had significantly lower atrial ejection force values compared with the other groups (P<0.05). Atrial fractional shortening was not significantly different among the three groups (P>0.05). Atrial ejection force, which is an indicator of left atrial contractility, is better with either angioplasty or thrombolysis. Left atrial volume is higher in patients who were not treated with reperfusion strategies. Further studies are needed to explain the mechanism involved.

Utility of myocardial performance index measured by left ventricular catheterization.

BACKGROUND: Myocardial performance index (MPI) is a valuable index of global ventricular performance. It is almost always measured by Doppler echocardiography. The purposes of this study were (I) to compare MPI measured by catheterization (MPIc) and that measured by Doppler echocardiography (MPId), and (2) to compare it with the functional status. MATERIALS AND METHODS: The study included 80 patients who had undergone left heart catheterization. The MPIc was measured from the pressure recordings obtained at left ventricle and aorta. RESULTS: Mean MPId and MPIc were 0.40 +/- 0.12 and 0.42 +/- 0.12, respectively. Mean left ventricular end diastolic pressure (LVEDP) was 13 +/- 5 mm Hg. Mean heart rate was 77 +/- 11 beats/min. Mann-Whitney U test revealed that MPIc could discriminate between the functional statuses of the patients. The regression analysis revealed that there is a good correlation between MPIc and MPId, LVEDP or heart rate. There was no significant difference between MPIc and MPId (p > 0.05). CONCLUSION: The present data show that (I) the MPIc has a strong correlation with MPId; (2) it is a good discriminator of functional status. It may provide an additional information regarding the left ventricular performance in patients who underwent the cardiac catheterization.

A different method for measuring mitral valve area with special emphasis on concomitant aortic regurgitation: A new application of proximal isovelocity surface area method.

Measurement of mitral valve area is still a challenge for the echocardiographers. Each method has its own limitations. In this study we assessed a different method and compared it with the other methods. The study included 50 consecutive patients with mitral stenosis. The reference method was planimetry. The suggested method was compared with the pressure half-time method, proximal isovelocity surface area method with and without angular correction, and the continuity method. There was a good correlation between each method and planimetry. The suggested method had the best correlation both for patients with and without aortic regurgitation. The pressure half-time method and continuity method overestimated the mitral valve area for patients with aortic regurgitation, whereas proximal isovelocity surface area method without angular correction overestimated the area in all patients. In conclusion, this method has very good correlation with planimetry. It can be used both in patients with and without aortic regurgitation.

Impedance cardiographic monitoring during pericardiocentesis: comparison with echocardiography.

OBJECTIVE: Thoracic impedance cardiography (TIC) is a noninvasive method which has proved to be useful in monitoring the haemodynamic status of the patients. In this study, we evaluated the TIC findings in patients with pericardial effusion and cardiac tamponade. METHODS AND RESULTS: The study consisted of patients with pericardial effusion with (group A) or without (group B) cardiac tamponade (CT). The stroke volume, cardiac output and ejection fraction was measured by both echocardiography and TIC. The measurements were done at baseline in both groups and following pericardiocentesis in group A. The variables were compared by linear regression analysis, paired sample's t test and chi-square test. The study included 32 patients. Group A consisted of 16 patients and group B of 14 patients. Two patients were excluded from comparisons because of insufficient quality of the echocardiographic examination. There were no significant differences between group A and B with regard to demographic features. Both echocardiographic and TIC measurements at baseline revealed decreased cardiac output, EDV and SV in group A and EF was not different. Linear regression analysis revealed that echocardiography and TIC were in significant correlation with regard to cardiac output, enddiastolic volume, stroke volume (p < 0.01) but not ejection fraction (p = 0.8910). The correlation was also present after pericardiocentesis. CONCLUSIONS: TIC can be safely used in patients with pericardial effusion. It provides suggestive data for the diagnosis of CT and can be used as a means of monitoring the results of the pericardiocentesis.

A large deletion (1.5 Mb) encompassing the neurofibromatosis type 1 (NF1) gene in a patient with sporadic NF1 associated with dysmorphism, mental retardation, and unusual ocular and skeletal features.

A 20 year old male patient with sporadic neurofibromatosis type 1 (NF1) is described with a large deletion (1.5 Mb) involving the NF1 gene, dysmorphism, mental retardation, and unusual ocular and skeletal features. Several NF1 patients with a large NF1 deletion and associated dysmorphism, and a large number of neurofibromas for their age have been described. This study indicates that such large deletions can also involve flanking loci which affect ocular and skeletal development.