The relationship between epicardial adipose tissue and ST-segment resolution in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

The relationship between epicardial adipose tissue (EAT) and coronary artery disease has been predominantly demonstrated in the last two decades. The aim of this study was to investigate the predictive value of EAT thickness on ST-segment resolution that reflects myocardial reperfusion in patients undergoing primary percutaneous coronary intervention (pPCI) for acute ST-segment elevation myocardial infarction (STEMI). The present study prospectively included 114 consecutive patients (mean age 54 ± 10 years, range 35-83, 15 women) with first acute STEMI who underwent successful pPCI. ST-segment resolution (ΔSTR) <70 % was accepted as ECG sign of no-reflow phenomenon. The EAT thickness was measured by two-dimensional echocardiography. EAT thickness was increased in patients with no-reflow (3.9 ± 1.7 vs. 5.4 ± 2, p = 0.001). EAT thickness was also found to be inversely correlated with ΔSTR (r = -0.414, p = 0.001). Multivariate logistic regression analysis demonstrated that EAT thickness independently predicted no-reflow (OR 1.43, 95 % CI 1.13-1.82, p = 0.003). Receiver operating characteristic curve analysis demonstrated good diagnostic accuracy for EAT thickness in predicting no-reflow [area under curve (AUC) = 0.72, 95 % CI 0.63-0.82, p < 0.001]. In conclusion, increased EAT thickness may play an important role in the prediction of no-reflow in STEMI treated with pPCI.

Transthoracic Doppler echocardiographic coronary flow imaging in identification of left anterior descending coronary artery stenosis in patients with left bundle branch block.

BACKGROUND: Conventional noninvasive methods have well-known limitations for the detection of coronary artery disease (CAD) in patients with left bundle branch block (LBBB). However, advancements in Doppler echocardiography permit transthoracic imaging of coronary flow velocities (CFV) and measurement of coronary flow reserve (CFR). Our aim was to evaluate the diagnostic value of transthoracic CFR measurements for detection of significant left anterior descending (LAD) stenosis in patients with LBBB and compare it to that of myocardial perfusion scintigraphy (MPS). METHODS: Simultaneous transthoracic CFR measurements and MPS were analyzed in 44 consecutive patients with suspected CAD and permanent LBBB. Typical diastolic predominant phasic CFV Doppler spectra of distal LAD were obtained at rest and during a two-step (0.56-0.84 mg/kg) dipyridamole infusion protocol. CFR was defined as the ratio of peak hyperemic velocities to the baseline values. A reversible perfusion defect at LAD territory was accepted as a positive scintigraphy finding for significant LAD stenosis. A coronary angiography was performed within 5 days of the CFR studies. RESULTS: The hyperemic diastolic peak velocity (44 +/- 9 cm/sec vs 62 +/- 2 cm/sec; P=0.01) and diastolic CFR (1.38 +/- 0.17 vs 1.93 +/- 0.3; P=0.001) were significantly lower in patients with LAD stenosis compared to those without LAD stenosis. The diastolic CFR values of <1.6 yielded a sensitivity of 100% and a specificity of 94% in the identification of significant LAD stenosis. In comparison, MPS detected LAD stenosis with a sensitivity of 100% and a specificity of 29%. CONCLUSIONS: CFR measurement by transthoracic Doppler echocardiography is an accurate method that may improve noninvasive identification of LAD stenosis in patients with LBBB.

Prevalence of patent foramen ovale in patients with migraine.

Recent evidence supports that the prevalence of patent foramen ovale is higher in patients with migraine with aura. We conducted a case-control study and searched for intra-atrial right to left shunt in 53 patients with migraine. PFO was detected by means of transthoracic echocardiography with administration of contrast medium during valsalva maneuver and the results were compared with age and sex matched 27 healthy controls. Patent foramen ovale was more frequent in the migraine group (p<.01). The percentages of PFO in migraine patients with aura, without aura and the control group were 66.7%, 47.4% and 22.2%, respectively. Our results are supportive of an association between PFO and migraine, especially with aura.

Evaluation of enalapril+losartan treatment with cardiopulmonary exercise test in patients with left ventricular dysfunction.

The aim of this study was to evaluate the effects of the combination of enalapril and losartan in patients with left ventricular systolic dysfunction by means of cardiopulmonary exercise test (CPET). Patients with left-ventricular systolic dysfunction and ejection fractions of 40% or less were included to the study. All patients were under the treatment of enalapril 20 mg once daily. The study group consisted of 20 patients (18 men, 2 women; mean age +/- standard deviation: 62.4 +/-6.5 years) and the comparison group consisted of 10 (8 men, 2 women; mean age 59.3 +/-11.9 years). The dose of 50 mg of losartan once daily was given additionally to the study patients. Breath-by-breath CPET was performed before administration of losartan and then 6-8 weeks later in the study group and 2 times with an interval of 6-8 weeks in the control group without any change in the treatment protocol. In the study group the average exercise times were 361 +/-192 and 454 +/-205 seconds (p = 0.001) before and after the study. Peak oxygen consumption ( VO2) values were 1,209 +/-366 and 1,284 +/-398 mL/minute before and after the study (p = 0.01). Anaerobic threshold VO2 values were 785 +/-187 and 855 +/-217 mL/minute before and after the study, respectively (p = 0.01). Peak heart rates (HR) were 141 +/-28 and 143 +/-22/minute (p = 0.35); peak VO2/HR values were 9.02 +/-3.1 and 9.3 +/-3 mL/minute (p = 0.4) before and after the study, respectively. On the other hand, in the control group, average exercise times were 556 +/-250 and 528 +/-251 seconds (p = 0.8); peak VO2 values were 1,502 +/-537 and 1,450 +/-501 mL/minute (p = 0.2); and anaerobic threshold VO2 values were 1,005 +/-338 and 975 +/-319 mL/min (p = 0.7), before and after the study respectively. At the highest comparable exercise stage for both tests in the study group the expired volume/oxygen consumption ( VE/ VO2) ratio declined from 35.1 +/-6.2 to 32.4 +/-5.6 (p = 0.007). VE values declined from 37.5 +/-10.9 to 33.9 +/-10.1 L (p = 0.02); heart rate declined from 140 +/-27 to 132 +/-21/minute (p = 0.02). No significant change was observed in the mentioned values for the control group. Addition of losartan to the standard therapy in patients with left ventricular systolic dysfunction improved exercise capacity and caused lower heart rate and ventilation requirements for the same exercise level.

Determinants of coronary flow abnormalities in obstructive type hypertrophic cardiomyopathy: noninvasive assessment by transthoracic Doppler echocardiography.

We aimed to visualize the coronary flow velocities (CFV) of patients with hypertrophic obstructive cardiomyopathy by using transthoracic Doppler echocardiography, and to determine the relationship between abnormal CFV patterns and conventional echocardiography indices. Guided by 2-dimensional echocardiography and Doppler color flow mapping, CFV in the distal left anterior descending coronary artery were measured in 21 patients with hypertrophic obstructive cardiomyopathy using a 3.5-MHz transducer. The results were compared with those of 18 control subjects. Abnormal systolic flow patterns were observed in 15 (71%) patients (11 systolic-reversal flow and 4 no systolic flow). For patients and control subjects, peak diastolic velocity and velocity-time integral obtained from distal left anterior descending coronary artery were higher (63 +/- 21 cm/s and 18.5 +/- 4 cm vs 41 +/- 11 cm/s and 14.2 +/- 5 cm, respectively; P <.01 for both) whereas peak systolic velocity and velocity-time integral were significantly lower (-17 +/- 10 cm/s and 4.5 +/- 6 cm vs 24 +/- 9 cm/s and 9.5 +/- 4 cm, respectively; P <.001 for both). Significant positive and negative correlations between diastolic CFV and septal thickness index (r = 0.79, P <.0001), and between systolic CFV and septal thickness index (r = -0.65, P <.005), have been observed. CFV abnormalities that could easily be recorded by a standard Doppler echocardiographic study seem to be related to septal thickness rather than the degree of obstruction in hypertrophic obstructive cardiomyopathy.

Assessment of the effects of various maneuvers on both atrial pressure changes.

The aim of the present study was to determine which maneuver causes the greatest pressure difference between both atria by measuring right and left atrial pressures simultaneously after certain maneuvers. Thirty-two coronary care unit patients, whom a Swan-Ganz catheter was inserted because of acute left ventricular dysfunction, hypotension, sinus tachycardia with unknown cause, were included in this study. The basal values of peak right atrium (RA) pressure and corresponding pulmonary capillary wedge pressure (PCWP) were measured via two separated transducers. Patients were tutored with several trials to perform breath holding, successive three strong coughs, Valsalva maneuver, 20 degrees head down, respectively. In the end of these maneuvers, the peak RA pressure and corresponding PCWP were measured simultaneously. All maneuvers caused an increase in RA pressure. The highest peak RA pressure was obtained by means of the Valsalva maneuver (7.6 +/- 5 versus 20.4 +/- 7.6 mmHg before and after Valsalva, respectively; P<0.001). PCWP (18.8 +/- 5.9 mmHg) increased only with coughing (21.2 +/- 6.7 mmHg, P<0.01) and 20 degrees head down maneuver (20 +/- 5.7 mmHg, P<0.05). The highest increase in pressure gradient between peak RA pressure and corresponding PCWP was observed during Valsalva maneuver (-11 +/- 6.6 vs. 2.3 +/- 5.9 mmHg, P<0.001). The lowest increase was obtained in 20 degrees head down maneuver (-11 +/- 6.6 vs. -8.5 +/- 5.8 mmHg, P<0.001). When measuring the pressure of both atria invasively and simultaneously, Valsalva maneuver was the most effective maneuver consistent with pressure difference in favour of RA among all the other maneuvers.

Double-orifice mitral valve associated with nonisolated left ventricular noncompaction--a case report.

Double-orifice mitral valve is a rare congenital anomaly. Although it is more frequently associated with other cardiac abnormalities, it may occur as an isolated lesion. There are 2 forms of myocardial noncompaction: isolated and nonisolated myocardial noncompaction. Nonisolated myocardial noncompactions are occasionally reported postnatally in association with congenital heart anomalies such as ventricular septal defect, pulmonic stenosis, and atrial septal defect. To our knowledge, this is the first case presentation reporting a double-orifice mitral valve associated with nonisolated myocardial noncompaction.

A case of coronary spasm induced by 5-fluorouracil.

Cardiotoxicity is an uncommon adverse effect of 5-fluorouracil (5-FU). Coronary artery spasm has been postulated to be involved in the mechanism of this incident Patients may present with angina, myocardial infarction, arrhythmias and/or even sudden death. When the drug is readministered, there is a high risk of relapse. The underlying mechanisms of cardiotoxicity are not yet fully understood, although coronary vasospasm may be responsible. We report one woman receiving 5-fluorouracil therapy with typical chest pain and electrocardiographic changes consistent with acute coronary syndrome. A resolving pain and normalisation of ECG changes with nitrate therapy and normal coronary arteries indicate that this incident was about a coronary spasm caused by 5-FU.

The effects of hormonal therapy on aortic stiffness and left ventricular diastolic function.

OBJECTIVE: The main objective of this study is to investigate the effects of oestrogen replacement therapy (ERT) and hormone replacement therapy (HRT) on aortic stiffness and on the left ventricular diastolic function, including tissue Doppler. METHODS AND RESULTS: The two study groups were composed of 20 postmenopausal women having HRT and 22 postmenopausal women having ERT. Each group was evaluated for aortic elasticity properties and the left ventricular diastolic function at both the pre-treatment stage and after 12 weeks of hormonal therapy. There was a significant improvement in beta index (5.2+/- 2.5 vs. 3.2+/- 2.2, p = 0.001), distensibility (5.2+/-3.7 vs. 6.1 +/-4.1 cm2 x dyn(-1) x 10(-3), p = 0.036) and mitral E/Em ratio (7.44 +/- 3.25 vs. 5.75 +/- .2.34, p = 0.004) with ERT. HRT was observed to improve aortic elasticity properties (for strain 10.7+/-4.7 vs. 12.8 +/-7.6%, for beta index 4.9+/-2.1 vs. 3.39+/- 2.4 and for distensibility 4.6+/- 2.1 vs.5.69 +/-4.1 cm2 x dyn(-1) x 10(-3)) and the mitral E/Em ratio (7.61 +/- 3.31 vs.5.81 +/-2.31, p = 0.003). CONCLUSION: Both ERT and HRT have an improving effect on aortic elasticity properties, as well as on the diastolic function.

Aortic stiffness in patients with cardiac syndrome X.

AIM: Recently, the close relationship between aortic stiffness and cardiovascular mortality has aroused the interest of investigators in carrying out studies related to aortic stiffness. This study aims to investigate the aortic stiffness parameters in patients with cardiac syndrome X, a disorder that is believed to be a generalized disturbance of the vasodilator function of small arteries. MATERIAL AND METHODS: 18 patients with typical chest pain and angiographically normal coronary arteries associated with a positive exercise test were included in the study. The control group consisted of 27 patients with angiographically normal coronary arteries and no ischaemia on exercise testing. Antianginal medication was withheld 4 weeks before the study and transthoracic echocardiography was performed using a Hewlett-Packard Sonos 1500 instrument with a 2.5 MHz phased array transducer. Ascending aorta diameters were measured on the M-mode tracing at a level 3 cm above the aortic valve. Diameter change, pulse pressure, aortic strain and distensibility were measured as aortic stiffness parameters. RESULTS: The aortic diameter change was less in the syndrome X group than in the control group (0.15 +/- 0.04 cm/m2 vs. 0.28 +/- 0.12 cm/m2, p < 0.001). Likewise, aortic strain (9 +/- 3% vs. 18 +/- 8%, p < 0.001) and distensibility (4.01 +/- 1.71 cm2 x dyn(-1) x 10(-3) vs. 9.95 +/- 5.08 cm2 x dyn(-1) x 10(-3), p < 0.001) was significantly lower in the syndrome X group than in the control group. CONCLUSION: The deterioration in aortic elasticity properties in patients with cardiac syndrome X suggests that this disease may be a more generalized disturbance of the vasculature.

Functional results in aortic root enlargement.

BACKGROUND: The hemodynamically efficient valves with effective orifice areas that are used in aortic valve replacement have been positively determined to affect postoperative exercise capacity. The aim of this study was to evaluate the functional effects of aortic root enlargement in the late postoperative period for patients with a small effective orifice area. METHODS: Nineteen patients with a small effective orifice area were included in the study. The study group comprised 9 patients who underwent isolated aortic valve replacement with 23-mm St. Jude Medical prosthetic valves and posterior aortic root enlargement. The control group comprised 10 patients in whom 19-mm and 21-mm St. Jude Medical prosthetic valves were implanted without aortic root enlargement. The patients were evaluated in the late postoperative period with echocardiography and cardiopulmonary exercise testing. RESULTS: The 2 groups were similar in anthropometric parameter values, follow-up periods, echocardiographic findings, and the gradients at the prosthetic aortic valve at rest; however, the anaerobic threshold, peak oxygen uptake, minute ventilation volume, and walk time were significantly higher in the study group ( P <.05). CONCLUSION: The choice of aortic root enlargement for the implantation of a valve with a larger effective orifice area is preferred by most of the surgeons over the implantation of a valve with a smaller effective orifice area. The late postoperative functional capacity of the patient is significantly improved with root enlargement. Surgeons should be encouraged to perform root enlargement in patients with a small effective orifice area, and such surgery may even be performed routinely in these patients.

[Myocardial noncompaction: two cases and review]. / Miyokardiyal "noncompaction": iki olgu nedeniyle derleme.

Myocardial noncompaction (MN) is a rare form of cardiomyopathy due to an arrest in endomyocardial embryogenesis. It is characterized by multiple prominent trabeculations with deep intertrabecular recesses in ventricular walls. The disease usually affects the left ventricle and may cause cardiac failure, arrhythmias, and systemic embolism. We would like to present two rare cases of MN with a poor long-term prognosis. The first case is an unique case in the literature having bioprosthetic valve implantation and associated with a recovery of heart failure after the operation, the second case is another interesting case because of the association of A-V complete block, and multiple structural cardiac abnormalities.

A new echocardiographic approach in assessing pulmonary vascular bed in patients with congenital heart disease: pulmonary artery stiffness.

OBJECTIVE: The state of pulmonary vascular bed in congenital heart disease is the predictor of the patients clinical condition, prognosis and outcome of surgical intervention. This study aims to investigate the condition of pulmonary vascular bed analyzing pulmonary artery stiffness by means of Doppler echocardiography. METHODS: Thirty-three patients (16 females, mean age 26+/-15 years) with various congenital heart diseases such as atrial septal defect (20 patients), ventricular septal defect (10 patients), patent ductus arteriosus (2 patients), atrioventricular septal defect (1 patient) were enrolled in this study. Systemic flow (Qs), pulmonary flow (Qp), systemic vascular resistance, pulmonary vascular resistance were calculated according to Fick method by using data obtained during left and right heart catheterization. Echocardiographically, pulmonary artery stiffness (PAS) was calculated by using maximal frequency shift (MFS) and acceleration time (AcT) of the pulmonary artery flow trace. PAS (kHz/sec)= MFS/AcT. RESULTS: Invasively, the average Qp/Qs, mean pulmonary artery pressure, and pulmonary vascular resistance were found as 2.58+/-1.25, 25+/-20 mmHg, and 135+/-217 dyn.sec.cm-5, respectively. Echocardiographically, PAS was found to be 33+/-17 kHz/sec. Pulmonary artery stiffness was correlated with mean pulmonary artery pressure (r=0.63; p<0.001) and pulmonary vascular resistance (r=0.55, p<0.001), while no relation was found with Qp/Qs. CONCLUSION: Estimation of pulmonary artery stiffness by using pulmonary flow maximal frequency shift and acceleration time obtained by means of Doppler echocardiography may give us an idea about the state of pulmonary vascular bed.

Cardiac resynchronization improves coronary blood flow.

Asynchronous ventricular activation, induced by left bundle branch block, is known to have deleterious effects on the systolic and diastolic functions of the left ventricle (LV). Cardiac resynchronization therapy (CRT) has been proposed as a complementary method to improve the LV systolic performance by restoring the synchronized contraction patterns in patients with advanced heart failure and left bundle branch block. However, the effect of CRT on myocardial blood flow is not well established. In the present study, we therefore examined the coronary blood flow in 20 patients with idiopathic dilated cardiomyopathy, implanted with a biventricular pacemaker according to the established CRT criteria. Color Doppler settings were adjusted for the optimal coronary flow imaging, and coronary flow velocities were obtained in all patients. Typical diastolic predominant phasic Doppler spectrum of the distal left anterior descending coronary artery (LAD) was recorded. Conventional echocardiographic variables, peak values of the diastolic and systolic LAD velocities, and the velocity time integrals were measured for three or five consecutive beats during CRT with pacemaker on and off. Successful CRT with biventricular pacing increased coronary blood flow velocities of the distal LAD in addition to its well-known benefits on the systolic and diastolic LV performance in patients with significant dyssynchrony. CRT decreased duration of mitral regurgitation and increased diastolic filling time. Peak diastolic velocities and velocity time integral of the distal LAD were increased significantly. In conclusion, successful CRT with biventricular pacing improves coronary blood flow velocities of the distal LAD.

Hydatid cyst in the wall of the ascending aorta.

Hydatid disease rarely involves the aortic wall. We report a case of hydatidosis involving the ascending aorta and the left atrium. The patient underwent replacement of the ascending aorta with a prosthetic Dacron graft and left atrial cystectomy. At the 6-month follow-up, she was leading a normal life.

Heart rate variability in patients with systemic sarcoidosis.

PURPOSE: The identification of subjects with systemic sarcoidosis at higher risk for sudden death is an unresolved issue. An influence of the autonomic activity on the genesis of ventricular arrhythmias was postulated. Heart rate variability (HRV) analysis provides a useful method to measure autonomic activity, and is a predictor of increased risk of death in various conditions. Therefore, the aim of the study was to evaluate HRV in patients with systemic sarcoidosis. METHODS: The study included 35 patients with biopsy proven systemic sarcoidosis who were not taking antiarrhythmic medications. Thallium scintigraphy was performed to all patients with systemic sarcoidosis. The cardiac sarcoidosis was accepted in 16 patients as abnormal thallium scintigraphy and normal coronary arteriography. The time-domain analysis of HRV was expressed as the standard deviation of all normal to normal NN intervals (SDNN) detected during 24-hour Holter monitoring. Twenty-four healthy subjects represented a control group for HRV analysis. RESULTS: There were no differences in age (44 +/- 13 years for cardiac sarcoidosis, 42 +/- 15 years for noncardiac sarcoidosis, and 40 +/- 10 years for control group; P = NS), sex (the ratio of female; 63%, 68%, and 55%, respectively; P = NS), and echocardiographic ejection fraction (63 +/- 10%, 67 +/- 8%, and 69 +/- 6%, respectively; P = NS) among study groups. The mean SDNN value of the group with cardiac sarcoidosis was significantly lower than both the group with noncardiac sarcoidosis and the control group (72 +/- 32 ms vs 110 +/- 46 ms and 152 +/- 36 ms; P < 0.05, respectively). CONCLUSION: HRV is decreased in patients with systemic sarcoidosis compared to the control group. This decreasing is more obvious in patients with cardiac sarcoidosis.

Comparison of coronary flow velocities between patients with obstructive and nonobstructive type hypertrophic cardiomyopathy: noninvasive assessment by transthoracic Doppler echocardiography.

BACKGROUND: We aimed to compare coronary flow velocity (CFV) measurements of patients with nonobstructive (NHCM) and obstructive hypertrophic cardiomyopathy (HOCM) by using transthoracic Doppler echocardiography (TTDE). METHODS AND RESULTS: In 11 patients with NHCM and 26 with HOCM, CFV in the distal left anterior descending (LAD) coronary was measured by TTDE (3.5 MHz) under the guidance of color Doppler flow mapping in addition to standard 2D and Doppler echocardiography. The results were compared with 24 normal participants who had no evidence of cardiac disease. Peak diastolic velocity of LAD was also higher in NHCM and HOCM than controls (52 +/- 14 cm/sec and 54 +/- 20 cm/sec vs 41 +/- 11 cm/sec, respectively, P < 0.01). The analysis of systolic velocities revealed abnormal flow patterns in 16 (61%) patients with HOCM (12 systolic-reversal flow and 4 no systolic flow) and 6 (54%) (5 reversal flow and 1 zero flow) patients with NHCM (-11 +/- 30 cm/sec and -13 +/- 38 cm/sec, vs 24 +/- 9 cm/sec, respectively, P < 0.001). Linear regression analysis demonstrated no correlation between intraventricular pressure gradient and coronary flow velocities in HOCM patients. However, there were significant positive and negative correlations between septal thickness and diastolic and systolic velocities, respectively (r = 0.50, P < 0.002, and r =-0.43, P < 0.005). CONCLUSION: We conclude that the coronary flow velocity abnormalities are independent from the type of hypertrophic cardiomyopathy.