Bleeding complications during cardiac electronic device implantation in patients receiving antithrombotic therapy: is there any value of local tranexamic acid?

BACKGROUND: The perioperative use of antithrombotic therapy is associated with increased bleeding risk after cardiac implantable electronic device (CIED) implantation. Topical application of tranexamic acid (TXA) is effective in reducing bleeding complications after various surgical operations. However, there is no information regarding local TXA application during CIED procedures. The purpose of our study was to evaluate bleeding complications rates during CIED implantation with and without topical TXA use in patients receiving antithrombotic treatment. METHODS: We conducted a retrospective analysis of consecutive patients undergoing CIED implantation while receiving warfarin or dual antiplatelet (DAPT) or warfarin plus DAPT treatment. Study population was classified in two groups according to presence or absence of topical TXA use during CIED implantation. Pocket hematoma (PH), major bleeding complications (MBC) and thromboembolic events occuring within 90 days were compared. RESULTS: A total of 135 consecutive patients were identified and included in the analysis. The mean age was 60 ± 11 years old. Topical TXA application during implantation was reported in 52 patients (TXA group). The remaining 83 patients were assigned to the control group. PH occurred in 7.7 % patients in the TXA group and 26.5 % patients in the control group (P = 0.013). The MBC was reported in 5.8 % patients in the TXA and 20.5 % patients in control group (P = 0.024). Univariate logistic regression analysis identified age, history of recent stent implantation, periprocedural spironolactone use, periprocedural warfarin use, perioperative warfarin plus DAPT use, cardiac resynchronization therapy, and topical TXA application during CIED implantation as predicting factors of PH. Multivariate analysis showed that perioperative warfarin plus DAPT use (OR = 10.874, 95 % CI: 2.496-47.365, P = 0.001) and topical TXA application during CIED procedure (OR = 0.059, 95 % CI: 0.012-0.300, P = 0.001) were independent predictors of PH. Perioperative warfarin plus DAPT use and topical TXA application were also found to be independent predictors of MBC in multivariate analyses. No thromboembolic complications was recorded in the study group. CONCLUSION: The present study demonstrated that the topical TXA application during CIED implantation is associated with reduced PH and MBC in patients with high bleeding risk.

Atrial fibrillation is associated with increased mean platelet volume in patients with type 2 diabetes mellitus.

Platelet abnormalities in diabetes mellitus (DM) and atrial fibrillation (AF) may underline the etiology of a prothrombotic state in these conditions. Increased mean platelet volume (MPV) is a marker of abnormal platelet function and activation. We aimed to investigate the possible association of chronic AF with MPV in patients who have type 2 DM. Patients who had type 2 DM with either chronic (≥6 months) AF or normal sinus rhythm (NSR) were included in the study. A total of 162 patients (aged 38-89 years) were divided into 2 groups according to the presence of either AF or NSR. Group 1 consisted of 81 diabetic patients with AF, and group 2 consisted of 81 diabetic patients with NSR. The two groups were not significantly different in terms of age, and gender, as well as in hypertension, smoking, history of coronary artery disease, previous cerebrovascular accidents, microalbuminuria, retinopathy, duration of DM, body mass index, hemoglobin A1c, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride (p > 0.05 for all variables). Although no significant difference was present between groups concerning platelet count; for patients with AF, MPV was higher compared with patients with NSR (9.0 ± 0.2 fl vs. 8.4 ± 0.2 fl; p = 0.001). Furthermore, no significant difference was noted between groups regarding routine medications received by patients. In multivariate logistic regression analysis, MPV was the only variable independently related to AF (OR = 2.659; 95% CI, 1.286-5.498; p = 0.008). Consequently, it is concluded that AF is associated with increased MPV in patients with type 2 DM, suggesting the presence of tentatively related processes leading to reciprocal interaction.

Increased d-dimer levels predict cardiovascular mortality in patients with systolic heart failure.

D-dimer is a fibrin degradation product, and is implicated in pathologies of cardiovascular system. Thrombosis within the vascular system in relation with inflammation and stasis might be associated with poor prognosis in patients with systolic heart failure (HF). In this study we aimed to investigate for relationship between d-dimer levels and cardiovascular mortality in patients with systolic HF. A total of 174 consecutive patients with hospitalized systolic HF were evaluated. All hospitalized patients were obtained d-dimer levels within the first 24 h following admission after obtaining informed consent. Patients were followed up for cardiovascular mortality and 40 (23%) patients died. d-dimer levels were higher among those who died compared to those who survived (2727 ± 2569 (710-4438) versus. 1029 ± 1319 (303-1061) ng/ml, P < 0.001). Optimal cut-off level of d-dimer to predict cardiovascular mortality was found to be >1435 ng/ml. D-dimer levels were negatively correlated with ejection fraction, positively correlated with left atrium size and left ventricular diastolic diameter. D-dimer >1435 ng/ml, age, diabetes mellitus, presence of atrial fibrillation, and creatinine level were found to have prognostic significance in univariate analyses. In multivariate Cox proportional-hazards model, d-dimer > 1435 ng/ml (HR = 3.250, 95% CI 1.647-6.414, P = 0.001), creatinine level (HR = 1.269, 95% CI 1.008-1.599, P = 0.043), and presence of atrial fibrillation (HR = 2.159, 95% CI 1.047-4.452, P = 0.037) remained associated with an increased risk of death after adjustment for variables found to be statistically significant in univariate analysis and correlated with d-dimer level. In conclusion, d-dimer measurement could help risk stratification in patients with systolic HF.

The relationship between D-dimer level and the development of atrial fibrillation in patients with systolic heart failure.

Heart failure (HF) is one of the most common and leading cause of death worldwide. Clinical trials provide evidence that the development of atrial fibrillation (AF) is a marker of poor prognosis in patients with HF. Furthermore, elevated D-dimer level is associated with increased cardiovascular mortality independent of AF in HF patients. We investigated whether plasma D-dimer levels in patients with hospitalized systolic HF could predict development of AF. A total of 150 consecutive patients with sinus rhythm who admitted to the emergency department with hospitalized systolic HF were evaluated. All hospitalized patients were obtained D-dimer levels within the first 24 h following admission. Atrial fibrillation developed in 31 (20.7%) patients during follow-up period of 6.3 ± 5 months. Patients who developed atrial fibrillation had significantly increased levels of D-dimer [608 (339-1,022) ng/ml versus 1,100 (608-2,599) ng/ml, P = 0.001]. Optimal cut-off level of D-dimer to predict development of AF was found to be >792 ng/ml. D-dimer >792 ng/ml, right ventricular dilatation, age, systolic pulmonary pressure, left atrium size, moderate to severe tricuspid regurgitation, and beta blocker usage were found to have prognostic significance in univariate analysis. In multivariate Cox proportional-hazards model, D-dimer levels >792 ng/ml (HR = 3.019, P = 0.006), and right ventricular dilatation (HR = 8.676, P = 0.003) were associated with an increased risk of new-onset AF. In conclusion, D-dimer could predict development of AF in patients with hospitalized systolic HF.

Increased γ-glutamyl transferase levels predict early mortality in patients with acute pulmonary embolism.

BACKGROUND: Increased γ-glutamyl transferase (GGT) level is associated with increased oxidative stress, all-cause mortality, the development of cardiovascular disease, and metabolic syndrome. However, its role in acute pulmonary embolism (PE) is unknown. In this study, we aimed to investigate the relationship between GGT and early mortality in patients with acute PE. METHODS: A total of 127 consecutive patients with confirmed PE were evaluated. The optimal cutoff value of GGT to predict early mortality was measured as more than 55 IU/L with 94.4% sensitivity and 66.1% specificity. Patients with acute PE were categorized prospectively as having no increased (group I) or increased (group II) GGT based on a cutoff value. RESULTS: Of these 127 patients, 18 patients (14.2%) died during follow-up. Among these 18 patients, 1 (1.4%) patient was in group I, and 17 (30.9%) patients were in group II (P < .001). γ-Glutamyl transferase level on admission, presence of shock, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, main pulmonary artery involvement, troponin I, alanine aminotransferase, alkaline phosphatase, and creatinine levels were found to have prognostic significance in univariate analysis. In the multivariate Cox proportional hazards model, GGT level on admission (hazard ratio [HR], 1.015; P = .017), presence of shock (HR, 15.124; P = .005), age (HR, 1.107; P = .010), and heart rate (HR, 1.101; P = .032) remained associated with an increased risk of acute PE-related early mortality after the adjustment of other potential confounders. CONCLUSIONS: We have shown that a high GGT level is associated with worse hemodynamic parameters, and it seems that GGT helps risk stratification in patients with acute PE.

Contrast-induced nephropathy: controlled study by differential GFR measurement in hospitalized patients.

BACKGROUND: Without appropriate control measures, contrast-induced nephropathy (CIN) incidence has been claimed to be overestimated. PURPOSE: To evaluate the relationship and the difference between differential serum creatinine (DsCr), which is currently surrogating as a marker of CIN, and measured differential GFR values as a control measure (DGFR) in hospitalized patients. MATERIAL AND METHODS: GFR was measured two times by Tc-99m DTPA, before and 48 h after contrast media (CM), along with sCr and BUN in 35 inpatients (22 men, 13 women, mean age ± SD = 61 ± 14) with no known chronic kidney disease. RESULTS: Relationship was moderate between GFR and sCr (R = 0.50, P < 0.01) in the study population. Pre-CM vs. post-CM values of GFR, sCr and BUN were not statistically different as (mean ± SD); 78 ± 36 vs. 73 ± 35 mL/min/1.73m(2), 0.95 ± 0.26 vs. 0.94 ± 0.26 mg/dl and 21 ± 16 vs. 19 ± 13 mg/dl, respectively, in the study group. According to basal GFR values, 14 patients (40%) seemed carrying risk of CIN (GFR < 60 mL/min/1.73m(2)) in whom only two had sCr >1.5 mg/dl. Twenty-five patients (71%) had discordant results in relation to DsCr and DGFR and two of them had CIN according to classical definition of DsCr, although having basal sCr <1.1 mg/dl. Yet, both had low, but stable GFR values. None of patient from the study group underwent hemodialysis. CONCLUSION: Significant discordance was observed between differential serum creatinine and measured differential GFR in hospitalized patients, suggesting that CIN incidence calculations only based on hospital registry may carry risk of error.

The product of eGFR and hemoglobin may help predict mortality in systolic heart failure patients without severe anemia and renal failure.

OBJECTIVES: Cardiorenal anemia syndrome is defined in patients with heart failure (HF). Although individual influences of renal impairment and anemia were shown previously, complex interaction between the kidney, bone marrow, and the heart renders decision making relatively inefficient in patients with milder forms of these diseases. We aimed to investigate whether product of estimated glomerular filtration rate (eGFR) and hemoglobin (Hb) predicts outcomes in patients with HF. STUDY DESIGN: The study included 148 consecutive patients (89 males, 59 females; mean age 68±10 years) who were hospitalized with acutely decompensated systolic HF and discharged alive. Discharge Hb levels were measured. Renal function was estimated via the MDRD (Modification of Diet in Renal Disease) formula. The eGFRxHb product was derived, and cut-off was defined using the ROC (receiver operating characteristic) analysis. The influence of eGFRxHb product on mortality was analyzed after a follow-up period of up to 34 months (mean 8.2±5.5 months). RESULTS: The mean Hb was 12.7±2 g/dl, the mean creatinine was 105±46 µmol/l, and the mean eGFR was 61±23 ml/min/1.73 m². Eighty-two patients (55.4%) had an eGFR of <60 ml/kg/m². During the follow-up, 27 patients died. Optimal cut-off level of eGFRxHb product to predict mortality was found to be ≤788 with a sensitivity of 82.6% and specificity of 51.3%. In multivariate Cox proportional analysis, only eGFRxHb product ≤788 (HR 4.488, 95% CI 1.500-13.433, p=0.007) and presence of atrial fibrillation (HR 2.644, 95% CI 1.113-6.280, p=0.028) were independent predictors of mortality in patients with HF. CONCLUSION: We concluded that the product of eGFR and Hb might be useful in prediction of mortality among patients with systolic HF.

The relationship between mean pulmonary artery pressure and quality of life in patients with mitral stenosis.

OBJECTIVES: We aimed to evaluate echocardiography-guided hemodynamic determinants of quality of life (QoL) via the Medical Outcomes Study Short Form (SF-36) questionnaire in patients with mild to moderate mitral stenosis (MS). METHODS: Eighty consecutive patients with rheumatic MS, who were admitted to the outpatient department, were enrolled into the study upon obtaining informed consent. Forty age-sex-matched healthy individuals were enrolled as a control group. RESULTS: All subscale scores and total SF-36 scores were significantly lower in the patient group representing a worse QoL. In multivariable logistic regression analysis, only mean pulmonary artery pressure (OR 1.138, 95% CI 1.049-1.234, p = 0.002) was found to be an independent predictor of poor QoL in patients with mild to moderate MS. CONCLUSION: During follow-up of MS patients before intervention, physicians should consider that mean pulmonary artery pressure is the main factor which influences the patients' QoL. In patients with MS, it seems that referral to intervention should consider components and derivatives of QoL.

Cardiac findings in children with Crimean-Congo hemorrhagic fever.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) involves the multi-organ systems. The involvement of the heart in adult patients has been described previously. We investigated the electrocardiographic and echocardiographic findings of pediatric patients with CCHF. MATERIAL/METHODS: Patients younger than 16 years of age diagnosed with CCHF were enrolled in the study. The diagnosis of CCHF infection was based upon typical clinical and epidemiological findings and serological tests. All patients underwent a thorough cardiologic evaluation. A standard 12-lead electrocardiography and echocardiography were performed. RESULTS: Twenty-three consecutive patients who were hospitalized with diagnosis of CCHF were enrolled in the study (mean age: 12±2 years, 6 female). All electrocardiographic parameters were within normal ranges according to age. Seven patients (30%) had minimal (<1 cm) pericardial effusion. Fifteen (65%) patients had segmental wall motion abnormalities (hypokinesia). A second echocardiography revealed that all wall motion abnormalities had disappeared; the pericardial effusion persisted in only 2 of 7 patients (28%). CONCLUSIONS: Cardiac involvement appears to be more frequent in children with CCHF disease than in adults, but it is slighter and almost totally reversible; however, the course of the disease in children is milder than it is in adults.

[Ventricular tachycardia caused by a left ventricular aneurysm in a patient with previous surgery for ventricular septal defect]. / Ventriküler septal defekt cerrahisi geçirmis bir olguda sol ventrikül anevrizmasina bagli ventrikül tasikardisi.

Ventricular mural aneurysms especially in the left ventricle represent an increased risk for life-threatening arrhythmias. We present a case of ventricular tachycardia originating from an inferobasal left ventricular aneurysm. A 25-year-old male patient presented with complaints of palpitation, breathlessness, and dizziness of two-hour onset. The electrocardiogram showed wide-QRS tachycardia at which time his blood pressure was 80/40 mmHg. The patient suddenly developed collapse and ventricular tachycardia was diagnosed on the monitor, and he returned to sinus rhythm following successful cardioversion. He remained stable during hospitalization. The electrocardiogram was in sinus rhythm with right bundle branch block and small Q waves in inferior leads. He had an eight-year history of surgery for ventricular septal defect closure, during which a ventricular aneurysm was detected but left untreated. Echocardiographic examination showed a dyskinetic aneurysmal region extending from the inferobasal segment to the posterior wall of the left ventricle. Coronary arteries were normal on angiography, and ventriculography confirmed the aneurysm. Electrophysiologic study was recommended, but the patient refused any treatment. He remained asymptomatic during 18 months of follow-up.

Development of malignant ventricular arrhythmias in a young male with WPW pattern.

In Wolff-Parkinson-White Syndrome (WPW), presence of accessory pathways causes various tachyarrhythmias that lead to different symptoms and clinical conditions in patients. Atrial fibrillation is observed in about 20-30% of this group of patients. Life threatening malignant ventricular arrhythmias and sudden cardiac deaths are observed in patients having rapid conduction in accessory pathways and short antegrade refractory periods (<250 msn). We present a WPW syndrome case that presented to the emergency service with narrow QRS tachycardia and later developed malignant ventricular arrhythmia.

Relationship between HbA1c and coronary flow rate in patients with type 2 diabetes mellitus and angiographically normal coronary arteries.

OBJECTIVES: We examined the relationship between glycosylated hemoglobin (HbA1c) level and coronary flow rate in patients with type 2 diabetes mellitus (DM) and angiographically normal coronary arteries. STUDY DESIGN: The study included 54 consecutive patients (36 males, 18 females; age range 37 to 72 years) with type 2 DM, whose coronary arteries were found normal on coronary angiography. All patients underwent echocardiography and plasma HbA1c levels were measured before coronary angiography. To determine slow coronary flow (SCF), coronary flow rates of the left anterior descending (LAD), circumflex (Cx), and right coronary (RCA) arteries were assessed using the TIMI frame count (TFC) method. RESULTS: None of the patients had echocardiographic abnormalities. The mean HbA1c level was 7.4±2.0%, and the mean TFCs were 34.3±6.5, 22.4±3.5, and 20.4±2.2 for the LAD, Cx, and RCA, respectively. HbA1c levels were <7% in 26 patients, and ≥7% in 28 patients. Thirty-eight patients (70.4%) were found to have SCF in at least one coronary artery. TIMI frame counts of all three coronary arteries were significantly greater in patients in whom HbA1c was ≥7% (p<0.001). TIMI frame counts showed significant correlations with the HbA1c level (LAD: r=0.782; Cx: r=0.707; RCA: r=0.515; p<0.001 for all). The mean HbA1c level was significantly higher in patients with SCF compared to patients without SCF (7.8±1.9% vs. 5.6±0.9%; p<0.001). The incidence of SCF was significantly greater in patients with HbA1c ≥7.0% than those with HbA1c <7.0% (96.4% vs. 61.5%; p=0.004). Increased HbA1c (≥7%) significantly increased the risk for SCF in at least one coronary artery (OR=16.875; 95% CI 1.972-144.38). CONCLUSION: Our findings suggest that there is a strong correlation between the HbA1c level and coronary flow rate.

Ecchymosis and Coldness in Peripheral Varicose Vein Patients: Observations From VEIN-TURKEY Study.

The purpose of this subgroup analysis is to investigate and analyze the venous leg symptoms including sense of coldness and sign of ecchymosis in patients with or without peripheral varicose veins (PVVs) from VEIN-TURKEY study population. A total of 600 patients, who were enrolled to VEIN-TURKEY study recently, were included in this subgroup analysis. Patients were examined clinically for the presence and severity of PVV and varicocele. Patients were asked to answer the VEINES-Sym questionnaire consisting of 10 parts and questions about ecchymosis and coldness in their legs. Frequency of symptoms present in the VEINES-Sym instrument, coldness (16.6%, 6.5%, P = .002, respectively), and ecchymosis (16.6%, 2.7%, P < .001, respectively) were significantly higher in patients with PVV compared to patients without PVV. Mean score of each symptom was significantly lower in PVV (+) patients including scores of ecchymosis and coldness. Total VEINES-Sym score was also correlated with the scores of ecchymosis (r = 0.18, P < .001) and coldness (r = 0.35, P < .001). Logistic regression analysis revealed that heavy legs, aching legs, night cramps, and ecchymosis are significantly and independently associated with PVV. In conclusion, sign of ecchymosis and coldness are significantly higher in patients with PVV compared to patients without PVV in a population recruited from the urology clinics. In clinical evaluation, presence or sign of ecchymosis and coldness in legs should be considered to be compatible with PVV in the absence of trauma, hematologic pathologies including antiplatelet treatment, and arterial stenosis or obstruction.

Dronedarone: a promising alternative for the management of atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is the most frequently encountered chronic arrhythmia associated with significant morbidity. It is generally encountered in the elderly, and will presumably become more prevalent in the future due to the increasing proportion of the elderly in the population. Major studies on AF have demonstrated no significant difference between rhythm and rate control in terms of mortality. However, young population with new-onset or lone AF, or patients in whom the maintenance of sinus rhythm is a must (due to recurrent thromboembolic events etc.) still gives rise to significant concerns related to the obligatory long-term prophylaxis. The long-term administration of the currently available conventional agents (amiodarone, dofetilide, sotalol, propafenone,flecainide etc.) is considered as a 'double edged sword' due to the presence of life-threatening adverse effects including pro-arrhythmia and organ toxicity associated with these agents. Several molecules are being developed for the management of AF. However, only a few novel agents confer promising results with respect to safety and efficacy issues in the major studies. DISCUSSION: Dronedarone is an amiodarone analogue without iodine moiety in its structure, and is similar to amiodarone with regard to its structural and electrophysiological properties. Dronedarone is largely denuded of the potentially life-threatening adverse effects of anti-arrhythmics. Major clinical studies have demonstrated both rhythm and rate-controlling efficacy of dronedarone compared to placebo without any serious adverse effects in patients with AF. However, the ANDROMEDA trial, a large scale study including patients hospitalized for symptomatic congestive heart failure (with severely depressed left ventricular systolic functions) was prematurely terminated due to the increased mortality in the dronedarone arm compared to placebo indicating a lack of safety in this group of patients. Conversely, the recently published ATHENA study (including more than 4,600 high risk patients, but excluding those with severe heart failure) demonstrated a significant reduction in cardiovascular hospitalizations and cardiovascular mortality with dronedarone compared to placebo. In contrast, the DIONYSOS study, comparing dronedarone with amiodarone, demonstrated better safety, but lower efficacy of dronedarone for the maintenance of sinus rhythm in patients with AF. CONCLUSION: Further clinical trials (including head to head comparison with other conventional anti-arrhythmics) are still required to determine the place of dronedarone in the management of AF. The present review focuses on basic and clinical aspects of dronedarone, a novel agent for the management of AF.

Comparative effects of levosimendan and dobutamine on right ventricular function in patients with biventricular heart failure.

Severe heart failure represents a major source of morbidity and mortality. Poor right ventricular function is an independent prognostic marker for mortality in patients with chronic heart failure. In this study, levosimendan (L) and dobutamine (D) in patients with severe chronic biventricular failure were compared. Forty consecutive patients, who were judged for inotropic therapy by their primary physicians, with acutely decompensated systolic heart failure and having moderate-to-severe right ventricular dysfunction with right ventricular fractional area change of

The risk factors for and prevalence of coronary artery disease in heavy vehicle drivers.

OBJECTIVE: To investigate the frequencies of risk factors and the prevalence of coronary heart disease (CAD) in heavy vehicle drivers. METHODS: This cross-sectional type study was conducted between November 2004 and September 2006 in heavy vehicle male drivers registered with the Sivas Professional Drivers Association, Sivas, Turkey. From 400 individuals, 200 heavy vehicle male drivers, and 200 control subjects, 90% were reached for the sample. A questionnaire including sociodemographic specifications, body mass index (BMI), and risk factors for CHD was performed and some blood and physiologic parameters such as lipid profiles, fasting glucose level, resting ECG, were checked in all individuals; if required exercise ECG and angiography was performed. RESULTS: The drivers' weight, body fat mass, triglycerides, very low-density lipoprotein, and BMI means were higher than the control group at a statistically significant level, and their mean high-density lipoprotein level, which is a protective factor for CAD, was lower than the control group at a statistically significant level. In the drivers' group, 9 of the 109 exercise ECGs (8.3%), and in the control group 3 of 61 (4.9%) were evaluated as abnormal. In 5% of the drivers, the exercise test was evaluated as positive and this prevalence was 1.7% in the control group (p=0.081). A total of 3.3% of the participants had a positive exercise ECG. CONCLUSION: Periodic health check-ups for heavy vehicle drivers would allow for the diagnosis of heart disease at an early stage and the initiation of necessary treatment. Health education for this group could also have a part in the decrease and elimination of some risk factors for CAD.

Venous leg symptoms in patients with varicocele: A multicenter assessment study (VEIN-TURKEY study).

OBJECTIVE: The aim of this study is to evaluate chronic venous disease symptoms by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire in varicocele patients. MATERIAL AND METHODS: The study was designed as a prospective, case controlled study and conducted in four hospitals from Turkey. A total of 600 patients who admitted to urology outpatient clinic were enrolled to the study. After the exclusion of 44 patients who do not match the inclusion criteria, the remaining 556 patients were examined for the presence and grade of varicocele and subsequently examined clinically for the presence of chronic venous disease findings. Finally, patients were asked to answer the VEINES-Sym questionnaire consisting of 10 items. All patients' demographic parameters, cardiovascular risk factors, other co-morbid diseases and drug usage were noted. RESULTS: Patients were classified into two groups: varicocele (+) group ( n = 269) and varicocele (-) group ( n = 287). VEINES-Sym scores of varicocele patients were lower compared to patients without varicocele (41.41 ± 5.21, 43.19 ± 3.22, respectively, p < 0.001). Grades of varicocele significantly but inversely correlated with VEINES-Sym score ( r = 0, -206, p = 0.001). Logistic regression analysis revealed that presence of varicocele irrespective of grading significantly and independently associated with the presence of aching (odds ratio: 2.054, 95% confidence interval: 1.265-3.338, p = 0.004) and throbbing (odds ratio: 2.586, 95% confidence interval: 1.353-4.943, p = 0.004). CONCLUSION: Varicocele patients have lower VEINES-Sym scores compared to patients without varicocele and this finding is inversely correlated with the degree of the varicocele. This association supports the hypothesis that there may be a systemic vessel wall abnormality in venous disease patients. Patients with symptoms related to vascular dilatation in any territory may deserve to be assessed systematically with the support of further clinical studies.

Acute heart failure and near-syncope associated with giant left atrial ball thrombus occluding left ventricular inflow tract.

A 70-year-old female patient was admitted to our department with symptoms and signs of acute heart failure and near syncope. After hospitalization, both transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) demonstrated a giant (4.9 x 3.9 cm) mobile, irregular, bright left atrial mass consistent with left atrial ball thrombus (LABT). The mass was found to occlude the left ventricular inflow tract (LVIT) above the mitral orifice (supravalvular) in the presence of normal mitral leaflets. After emergent surgical excision, the pathology of the left atrial mass was found to be consistent with thrombus. The case presented here suffered acute diastolic heart failure and near-syncope due to obstruction of the LVIT above the mitral orifice by a giant LABT.

A giant coronary sinus mimicking descending aorta.

A 58-year-old male patient was admitted to the emergency service with dyspnoea.The patient underwent several laboratory and imaging tests including echocardiography and a diagnosis of descending aortic aneurysm was suspected.After computerised tomography scanning, a normal-size descending aorta was found so that echocardiography was done once more. Intravenous contrast examination revealed a giant coronary sinus in this patient.