The importance of baseline fractional flow reserve to detect significant coronary artery stenosis in different patient populations.

INTRODUCTION: Fractional flow reserve (FFR) assessment compares the blood flow on either side of a blockage in the coronary artery and indicates how severe the stenosis is in the artery. Intravenous adenosine is widely used to achieve conditions of stable hyperaemia for the measurement of FR. However, intravenous adenosine affects both systemic and coronary vascular beds differentially. Therefore, FFR has some limitations, such as the side effects of adenosine and the long procedure time. In addition, there are not enough studies on the evaluation of the baseline ratio of distal coronary pressure to aortic pressure (Pd/Pa) according to standard cut-off values in coronary stenosis under special clinical conditions. This study aimed to assess the diagnostic power of the baseline FFR value for critical coronary stenosis and to determine its predictive value in special patient groups. METHODS: This retrospective study included 158 patients, who were stratified as Q1 (< 0.89), Q2 (0.89-0.92), Q3 (0.93-0.95) and Q4 (> 0.95) based on baseline FFR values. The baseline Pd/Pa value, the change in adenosine FFR and the raw FFR change were recorded. Its predictive value was also calculated for specific patient groups. RESULTS: The threshold value of baseline FFR level for predicting critical stenosis was ≤ 0.92 with a sensitivity of 92.8% and a specificity of 82% (upper limit of Q2 cartilage). Patients with a baseline FFR value ≤ 0.92 had a 58.4-fold greater likelihood of a critical outcome compared with patients with a baseline FFR value > 0.92 (OR: 58.4; 95% CI: 20.3-124.6). In patients with a baseline FFR ≤ 0.92, the Q1 group had a 10.23-fold higher odds of critical stenosis compared with the Q2 group (OR: 10.23; 95% CI: 2.14-48.84). The same values had similar diagnostic power for all specific patient groups. CONCLUSION: The baseline FFR value could be used to predict critical coronary stenosis in our patients and had similar value for predicting lesion severity in all the subgroups.

The diagnostic utility of the basal and post-exercise QRS-T angle in patients with stable coronary artery disease.

BACKGROUND: To evaluate the diagnostic utility of basal and post-exercise QRS-T angle in patients with stable coronary artery disease (CAD). METHODS: This cross-sectional and observational study analyzed 190 patients with stable angina. The QRS-T angle is measured on the 12-lead electrocardiograms at baseline and just after stopping the treadmill stress test in patients undergoing conventional coronary angiography (CAG). The pre- and post-exercise QRS-T angle and ΔQRS-T angle were analyzed. RESULTS: Of the 190 patients, 66 (34.7%) were assigned to group 1 (patients with coronary lesion) and 124 (65.3%) to group 2 (patients without coronary lesion) after CAG. There was no statistically significant difference in QRS-T angle between groups at baseline (pre-exercise) (30.7 ± 17 vs. 27.8 ± 12.8, p = .233). The QRS-T angle value was significantly higher in group 1 than in group 2 (68.8 ± 40.3 vs. 22.7 ± 21.5, p = .01) after exercise (post-exercise). The ΔQRS-T angle was also significantly higher in group 1 than in group 2 (38.1 ± 37.6 vs. -5.1 ± 22.9, p = .01). Receiver operating characteristic curve revealed that the cut-off value of QRS-T angle (post-exercise) for the coronary obstruction was >51.5° with 81% of sensitivity and 66% of specificity (AUC: 0.832, p = .001, CI: 0.769-0.894). Duke treadmill score for coronary stenosis was >1.5 with 77% of sensitivity and 69% of specificity (AUC: 0.814, p = .001, CI: 0.749-0.878). CONCLUSION: It could be proposed that post-exercise QRS-T angle and Δ QRS-T angle are significantly associated with coronary obstruction in patients with stable angina and appear to be more sensitive than the Duke treadmill score and traditional electrocardiographic parameters.

Approach to decongestion therapy in patients with acute decompensated heart failure: the echocardiography guided strategy.

Goal The E / (Ea×Sa) index is an echocardiographic parameter to determine a patient's left ventricular filling pressure. This study aims to determine the safety and efficacy of the echocardiographic E / (Ea×Sa) index guided diuretic therapy compared to urine output (conventional) guided diuretic treatment.Material and Methods In this cross-sectional study, patients with heart failure with reduced ejection fraction (HFrEF) who were hospitalized due to acute decompensation episode were consecutively allocated in a 1:1 ratio to monitoring arms. The diuretic dose, which provided 20 % reduction in the E / (Ea×Sa) index value compared to initial value, was determined as adequate dose in echocardiography guided monitoring group. The estimated glomerular filtration rate (eGFR), change in weight, NT pro-BNP level and dyspnea assessment on visual analogue scale (VAS) were analyzed at the end of the monitoring.Results Although the similar doses of diuretics were used in both groups, the patients with E / (Ea×Sa) index guided strategy had the substantial lower NT pro-BNP level within 72 hours after diuretic administration (2172 vs.2514 pg / mL, p= 0.036). VAS score on dyspnea assessment was significantly better in the patients with E / (Ea×Sa) index guided strategy (52 vs. 65; p= 0.04). And, in term of body weight loss (4.93 vs.5.21 kg, p=0.87) and e-GFR (54.58±8.6 vs. 52.65±9.1 mL / min / 1.73 m2p=0.74) in both groups are associated with similar outcomes. In both groups, there was no worsening renal function and electrolyte imbalance that required stopping or decreasing loop diuretic dosing.Conclusions The E / (Ea×Sa) index guidance might be a safe strategy for more effective diuretic response that deserves consideration for selected a subgroup of acute decomposed HFrEF patients.

High Eosinophil Rates in Patients With Right-to-Left Shunts: An Expected Role, or an Unexpected Risk?

Background and objective Eosinophils are associated with thromboembolic events. Since eosinophils are eliminated in the pulmonary vasculature, right-to-left shunt (RLS) through patent foramen ovale may increase eosinophils in the peripheral blood. In this report, we evaluated the eosinophils of patients with regard to the presence of RLS and its quantity. Patients and methods In this retrospective observational study, we analyzed the complete blood cell count (CBC) of patients with RLS (n=47) and without RLS (n=31) diagnosed by contrast echocardiography (CE). RLS was identified as mild (5-10 bubbles) and moderate shunt (10-25 bubbles). Results Age and CBC were not significantly different between the groups, with the exception of eosinophils. Patients with RLS had higher eosinophils percentage compared to patients without RLS (3.1 ±1.5 vs. 1.7 ±0.7, p=0.001). Additionally, eosinophils percentage was significantly higher in the mild RLS group (2.4 ±0.9 vs. 1.7 ±0.7, p=0.016) and the moderate RLS group (4.3 ±1.6 vs. 1.7 ±0.7, p=0.001) compared to normal subjects. Also, it was significantly higher in the moderate RLS group compared to the mild group (4.3 ±1.6 vs. 2.4 ±0.9, p=0.001). Conclusions Eosinophils percentage was higher in patients with mild and moderate RLS compared to normal individuals. Moreover, the eosinophil rate was higher in patients with moderate RLS than in patients with mild RLS.

An early echocardiographic prediction for functional myocardial recovery after ST elevation myocardial infarction.

Goals Discrimination of the time course of functional recovery in early period following ST elevation myocardial infarction (STEMI) has prognostic importance. This study aims to establish the ability of the combined systolic-diastolic index (E / (Ea x Sa), for differentiating recoverable myocardium or persistent non-viability in subjects with STEMI.Material and methods 77 patients with first acute STEMI were enrolled to the study. Serial transthoracic echocardiography (TTE) examinations were performed at the time of the admission (immediately after reperfusion), hospital discharge (5±1 days) and control examination (30±2 days). To assess the association between E / (Ea×Sa) index and myocardial recovery, two categories (Transient stunning and persistent non-viability) were defined on basis of improvement of left ventricle ejection fraction (LV EF) (Improvement was defined as an increase more than 10 % in LV EF at day 30 compared to baseline).Results 55 patients (71.4 %) had improvement of LV EF and 24 patients (28.6 %) had no recovery of systolic function (30 days LV EF 48.78±6.1 vs. 39.31±8.1 %, p=0.01). The E / (Ea×Sa) index were significantly higher in the "non-viability" than in stunning group on predischarge and 1 month (1.61±0.64 vs 1.25±0.43, p=0.01 and 1.33±0.25 vs 1.14±0.21, p=0.01, respectively). The change in the E / (Ea×Sa) index in early period (within 5±1 days) was higher in the stunning group (26 %) compared to non-viability group (15 %) (p=0.033). E / (Ea×Sa) index was found to be a significant predictor of myocardial recovery in multivariable logistic regression (OR 0.91, 95 % CI 0.83-0.98, p=0.001). Roc curve showed that the cutoff value of E / (Ea×Sa) index is 1.29 with 73 % of sensitivity and 61 % of specificity (AUC: 0.71, p=0.01, CI: 0.54-0.89).Conclusions Our findings suggest that E / (Ea×Sa) index is a strong predictor of functional recovery; the odds of recovery decreases as E / (Ea×Sa) index value increases.

Gender-related clinical and management differences in patients with chronic heart failure with reduced ejection fraction.

AIM: Gender-related differences have been described in the clinical characteristics and management of patients with chronic heart failure with reduced ejection fraction (HFrEF). However, published data are conflictive in this regard. METHODS: We investigated differences in clinical and management variables between male and female patients from the ATA study, a prospective, multicentre, observational study that included 1462 outpatients with chronic HFrEF between January and June 2019. RESULTS: Study population was predominantly male (70.1%). In comparison to men, women with chronic HFrEF were older (66 ± 11 years vs 69 ± 12 years, P < .001), suffered more hospitalisations and presented more frequently with NYHA class III or IV symptoms. Ischaemic heart disease was more frequent in men, whereas anaemia, thyroid disease and depression were more frequent in women. No difference was seen between genders in the use rate of renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or ivabradine, or in the proportion of patients achieving target doses of these drugs. Regarding device therapies, men were more often treated with an implantable cardioverter-defibrillator (ICD) and women received more cardiac resynchronisation therapy. CONCLUSION: In summary, although management seemed to be equivalent between genders, women tended to present with more symptoms, require hospitalisation more frequently and have different comorbidities than men. These results highlight the importance of gender-related differences in HFrEF and call for further research to clarify the causes of these disparities. Gender-specific recommendations should be included in future guidelines in HFrEF.

A New Perspective for Isolated Coronary Artery Ectasia: Cystatin C.

Introduction The pathophysiology of isolated coronary artery ectasia (iCAE) has not been clearly identified, although multiple abnormalities, including arteritis, endothelial dysfunction, and vascular destruction, have been reported. In this study, we aimed to analyze serum cystatin C concentrations in patients with iCAE and controls. Methods Forty-seven patients with iCAE (mean age: 55.9 ± 11.5) and 32 individuals with normal coronary angiography (mean age: 57.8.1 ± 9.6) were included in the study. Plasma cystatin C levels were measured by using the principle of particle-enhanced turbidimetric immunoassay (PETIA). Results Serum cystatin C concentrations were significantly lower in patients with iCAE compared with the control group (0.98 ± 0.17 mg/L versus 1.17 ± 2.6 mg/L, p-value = 0.001). A significantly positive relationship was found between serum cystatin C levels and creatinine and high-sensitivity C-reactive protein (hs-CRP) levels in both groups (r-value = 0.288, p-value = 0.005, r-value = 0.143, p-value = 0.007, respectively). In multivariate logistic regression analysis, serum cystatin C level found to be a significant predictor for the presence of iCAE (OR: 0.837, CI: 95% (0.341 - 1.637), p-value = 0.013). Receiver operating characteristic (ROC) analysis determined that a cystatin C value < 1.02 mg/L had a sensitivity of 56% and a specificity of 78% for the prediction of ectasia. Conclusion We conclude that cystatin C independently can be a useful predictor for the presence of iCAE.

The predictive value of the combined systolic-diastolic index for atrial fibrillation after coronary artery bypass surgery.

OBJECTIVE: Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is a factor that causes an increase in mortality and morbidity. Therefore, predicting post-CABG AF development is important for treatment management. In this study, we investigated the value of the ratio E/(Ea × Sa) as a combined systolic-diastolic index in predicting post-CABG AF development. METHODS: This prospective study included 102 patients who underwent only isolated coronary bypass. Preoperative demographic features, biochemical, and hematological parameters, and the electrocardiographic data of all patients were recorded. The E/(Ea × Sa) indices were calculated from the echocardiographic measurements. Those who retained their postoperative sinus rhythm were defined as group 1, and those who developed AF were defined as group 2. RESULTS: Group 2 had significantly higher lateral (group 1:1.14 ± 0.61 vs. group 2:1.47 ± 0.87; P = .02), medial (group 1:1.61 ± 0.70 vs. group 2:1.99 ± 0.91; P = .02), and mean (group 1:1.30 ± 0.58 vs. group 2:1.62 ± 0.74; P = .001) E/(Ea × Sa) indices than group 1. In the univariate analysis, age, CHA2 DS2 -VASc score, sPAP, IABP use, and mean E/(EaxSa) index were found to be significant predictors of post-CABG AF development. However, only the mean E/(EaxSa) index was found to be a significant predictor of post-CABG AF development in the multivariate analysis (OR: 2.19 95% CI 1.01-5.96; P = .045). CONCLUSIONS: The combined systolic-diastolic index predicted the development of post-CABG AF.

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study.

OBJECTIVE: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%). METHODS: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. RESULTS: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin-angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). CONCLUSION: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

A very rare coronary artery anomaly: Twin circumflex arteries associated with acute coronary syndrome - two cases report.

Circumflex coronary artery anomalies are the most common type so far observed. However, a dual origin of the circumflex is an extremely rare anomaly. We describe two different patients admitted to our clinic with acute coronary syndrome at the same day. Angiography revealed twin circumflex arteries: one from the left main artery and the other from the proximal right coronary artery.

Axillary artery as alternative access for transcatheter aortic valve implantation in a patient with thoracic and abdominal multilayer flow modulator stents, and in a patient with occluded bilateral carotid and iliac arteries.

Transaxillary access is an alternative to femoral access in patients with iliofemoral occlusion for transcatheter aortic valve implantation (TAVI). A Multilayer Flow Modulator (MLFM) stent is frequently used in patients with a complex thoracic and abdominal aortic aneurysm. The MLFM stent is particularly used in cases where large arteries, such as the renal or celiac artery, feed from the aneurysmal sac. To the best of our knowledge, there is no prior report in the literature of a TAVI case with a pre-existing MLFM stent. Presently described are 2 TAVI cases, one with thoracoabdominal MLFM stents, and the second with occluded bilateral carotid and iliac arteries.

An extensive caseous calcification of the mitral annulus complicated with severe mitral regurgitation.

Caseous calcification of the mitral annulus (CCMA) is considered a rare variant of mitral annular calcification (MAC) due to caseous transformation of the inner material and prevalence of CCMA, about 0.63% of all MAC cases and 0.06%-0.07% of the population. The precise pathophysiology of CCMA is still unknown. It is a chronic degenerative disorder common in the elderly, particularly in women. Caseous calcification of the mitral annulus (CCMA) is a soft peri-annular extensive calcification, resembling cardiac tumors, abscesses, vegetation, or calcified thrombus, which is composed of an admixture of calcium, fatty acids, and cholesterol with a toothpaste-like texture. In the characteristic appearance on echocardiography, the calcification is a round, large, soft mass with a central echo dense area, typically located at the basal area of the posterior mitral valve. It usually carries a benign prognosis but rarely may be complicated with mitral valve dysfunction (valve stenosis/mitral regurgitation) or systemic embolization. The current data suggest conservative medical therapy and clinical follow-up for management of CCMA unless there is a need of cardiac surgery for severe mitral stenosis and/or regurgitation. We present a case, complicated with severe mitral regurgitation, and need surgical resection of the CCMA because of the CCMA-induced symptomatic severe mitral regurgitation despite optimal medical therapy. Macroscopic and microscopic examination of caseous material also demonstrated the characteristic appearance of CCMA.

An alternative treatment for iatrogenic right ventricular puncture in primary percutaneous intervention.

Right ventricle perforation is an uncommon, but potentially fatal, possible complication of pericardiocentesis. We presented a case of right ventricular perforation that developed during urgent pericardiocentesis due to tamponade. This case was successfully treated with the incremental removal of the drainage catheter, replacing it with a smaller catheter at 10-minute intervals. This may be an alternative option to treat iatrogenic right ventricle puncture occurring during pericardiocentesis without cardiac surgery or a vascular closure device.

Transcatheter closure of atrial septal defect with atrial septal occluder in a patient with nickel allergy.

Presently described is transcatheter closure of atrial septal defect with atrial septal occluder (ASO) device in a patient with nickel allergy. Patients with metal allergy who will undergo nitinol device implantation should be tested for possible nickel hypersensitivity. ASO device and treatment strategy (percutaneous or surgical) should be selected according to allergy test result.

The impact of cardiac rhythm on the mitral valve area and gradient in patients with mitral stenosis.

OBJECTIVE: The aim of this study was to evaluate the effect of cardiac rhythm on the echocardiographic mitral valve area (MVA) and transmitral gradient calculation in relation to net atrioventricular compliance (Cn). METHODS: Patients (n=22) with mild or moderate pure rheumatic mitral stenosis (MS) (MVA <2 cm2 and MVA >1 cm2) and atrial fibrillation (AF) were evaluated. All patients underwent transthoracic electrical DC cardioversion under amiodarone treatment. Nineteen of the 22 patients were successfully converted to sinus rhythm (SR). The patients were evaluated with transthoracic echocardiography before and two to three days after DC cardioversion. In order to deal with variable R-R intervals, the measurements were averaged on five to eight consecutive beats in AF. Cn was calculated with a previously validated equation [Cn (mL/mm Hg)=1.270 x MVA/E-wave downslope]. The Cn difference between AF and SR was calculated as follows: [(AF Cn-SR Cn)/AF Cn] x 100. The percentage gradient (mean or maximal) difference between AF and SR was calculated as follows: [AF gradient (mean or maximal) - SR gradient (mean or maximal)]/[AF gradient (mean or maximal)] x 100. RESULTS: The MVA was lower (MVA planimetric; 1.62±0.29 vs. 1.54±0.27; p=.003, MVA PHT; 1.66±0.30 vs. 1.59±0.26; p=0.01) but transmitral gradient (mean gradient; 6.49±2.51 vs. 8.89±3.52; p=0.001, maximal gradient: 16.94±5.11 vs. 18.57±4.54; p=0.01) and Cn values (5.37±0.77 vs. 6.26±0.64; p<0.001) were higher in the AF than SR. There was a significant correlation between Cn difference and transmitral gradient difference (mean and maximal) (Cn difference-mean gradient difference; r=0.46; p=0.05; Cn difference-maximal gradient difference; r=0.72; p=0.001). CONCLUSION: Cardiac rhythm has a significant impact on echocardiographic evaluation of MVA, transmitral gradient, and Cn in patients with MS.

Quantitative assessment of the effect of subclavian steal syndrome on left anterior descending artery flow.

We presented a case of subclavian steal syndrome which has been evaluated and treated quantitatively by using fractional flow reserve technique. Treatment strategy to resolve symptoms of angina in patients with steal syndrome is controversial. Quantitative evaluation should direct choice of treatment strategy.

Hourglass-shaped right ventricle and localized constrictive pericarditis.

Constrictive pericarditis is characterized by thick pericardial fibrosis and frequent calcification that progressively impairs diastolic filling of the heart. The diagnosis of constrictive pericarditis has been challenging even though multiple diagnostic modalities have been developed. The diagnosis of constructive pericarditis is especially difficult in localized constrictive pericarditis which is extremely rare. We report a case of localized constrictive pericarditis with a 3D multislice cardiac computed tomography (CT) finding of the constrictive band causing strangulation and hourglass shaping of the right ventricle.

A Novel Index Combining Diastolic and Systolic Tissue Doppler Parameters for Prediction of Atrial Fibrillation Recurrence.

OBJECTIVE: Identification of patients at risk for atrial fibrillation (AF) recurrence with using simple and objective parameters may be helpful in tailoring the treatment. In this study, we investigated whether E/(Ea×Sa) and Ea/(Aa×Sa) could be a predictor of AF recurrence after cardioversion. (E = early diastolic transmitral velocity, Ea = early diastolic mitral annular velocity, Aa = late diastolic mitral annular velocity, Sa = systolic mitral annular velocity). METHODS: In total, 127 patients with persistent AF were evaluated for this study and 73 patients were included according to the study criteria. Sinus rhythm (SR) was achieved for 70 patients after electrical direct-current cardioversion. E, Sa, Ea, and Aa were determined at mitral medial and lateral site and average values obtained. E/(Ea×Sa) and Ea/(Aa×Sa) were calculated (medial, lateral, average). Heart rate and rhythm were followed with an electrocardiography (ECG) monitor and 12-lead ECG at first week and first month. RESULTS: At one month, 53 patients (75.7%) were in SR, whereas 17 patients (24.3%) reverted to AF. According to precardioversion E/(Ea×Sa) lateral, E/(Ea×Sa) medial, E/(Ea×Sa) average (P ≤ 0.01 for all the indices), 24-hour echocardiographic evaluation E/(Ea×Sa) lateral, E/(Ea×Sa) medial, E/(Ea×Sa) average, Ea/(Aa×Sa) lateral, Ea/(Aa×Sa) medial, and Ea/(Aa×Sa) average (P ≤ 0.01 for all the indices), indices were significantly higher in the AF recurrence group than in the SR group. Furthermore, the ROC analysis showed that all the E/(Ea×Sa) and Ea/(Aa×Sa) parameters predict the AF recurrence. The AUC values range from 70% to 81% (P ≤ 0.01 for all the parameters). In subgroup analysis of the patients, precardioversion mitral medial E/Ea ratio was between 8 and 15, and the ROC analysis showed that the novel indices predict the AF recurrence. The AUC values range from 72% to 86% (P ≤ 0.02 for all the parameters). CONCLUSIONS: We found that E/(Ea×Sa) and Ea/(Aa×Sa) indices are novel predictors of AF recurrence.

A Very Rare Coronary Artery Anomaly: Two Circumflex Arteries Originating From Both Right and Left Coronary Sinuses of Valsalva.

Coronary anomalies are found in less than 1% of diagnostic coronary angiograms. The clinical importance of coronary anomalies varies from insignificant to life-threatening. We report a very rare case of a patient with two circumflex arteries originating from both right and left coronary sinuses of Valsalva.