Influence of cardiac biomarkers on predicting significant coronary artery disease in hypertrophic cardiomyopathy patients.

BACKGROUND: In this study, our aim was to investigate the role of cardiac biomarkers in predicting the presence of significant coronary artery disease in hypertrophic cardiomyopathy (HCM) patients. METHODS: The study population was composed of hypertrophic cardiomyopathy patients who underwent coronary angiography at a single center between June 2021 and March 2023, and whose cardiac biomarkers were evaluated before the procedure. HCM patients were screened retrospectively. Significant CAD was defined as > 50% stenosis of the left main coronary artery or > 70% stenosis in a major coronary vessel. Demographic, echocardiographic and cardiac biomarker values were compared between the two groups. RESULTS: A total of 123 patients were evaluated. Significant CAD was detected in 39 (31.7%) patients. Patients with significant CAD had higher CK-MB values than those without CAD [2.8 (2.1-4.0) vs. 3.4 (2.8-4.6), p = 0.036], and a higher level of high-sensitivity troponin T (hs-TnT) than those without CAD (24 vs. 17.8, p = 0.022). the NT-proBNP/hs-TnT ratio was found to be significantly lower in patients with CAD than in those with CAD (31.4 vs. 21.4, p = 0.019). In multivariate anaylsis, NT-proBNP/hs-TnT was determined as an independent predictor for significant CAD. In ROC analysis, NT-proBNP/hs-TnT ratio lower than the cut-off value of 30.7 could detect the presence of significant CAD with 76.9% sensitivity and 53.6% specificity (AUC: 0.632, 95% CI: 0.528-0.736, p = 0.019). CONCLUSION: To sum up, we suggest that cardiac biomarkers were valuable and simple parameters in terms of significant CAD in HCM patients.

Bioprosthetic aortic valve thrombosis under effective direct oral anticoagulant therapy.

With the increase in transcatheter procedures, the use of bioprosthetic valves has become more frequent in clinical practice. However, the optimal antithrombotic management of patients with bioprosthetic valves remains controversial. In this case report, we describe a patient with a bioprosthetic aortic valve who developed a thrombus while receiving effective dose direct oral anticoagulant (DOAC) therapy. A 73-year-old male patient with a bioprosthetic aortic valve replacement 2 years prior presented with a mobile thrombus and early degeneration of the valve, detected during routine follow-up while being treated with apixaban. Although the valve thrombus regressed after switching to a different anticoagulant drug, we observed that the decreased but still high gradient persisted due to the early degeneration. Anticoagulant management of bioprosthetic valve patients demands careful attention. Although evidence supporting the use of DOACs is growing, close patient follow-up and further evaluation in case of doubt remain critical. The development of a thrombus in a bioprosthetic valve patient who is receiving anticoagulation therapy, as in this case, highlights the need for optimal management to prevent thromboembolic complications and valve degeneration.

Relationship between myocardial bridging and fatal ventricular arrhythmias in patients with hypertrophic cardiomyopathy: the HCM-MB study.

BACKGROUND: Myocardial bridging (MB) and hypertrophic cardiomyopathy (HCM) are associated with the risk of fatal ventricular arrhythmias (VAs). The goal of the study was to determine the relationship between MB and fatal VAs in HCM patients with implantable cardiac defibrillators (ICD). METHODS: A total of 108 HCM patients (mean age: 46.6 ± 13.6 years; male: 73) were enrolled in this retrospective study. All patients underwent transthoracic echocardiography and coronary computed tomography angiography. Fatal VAs including sustained ventricular tachycardia and ventricular fibrillation were documented in ICD records. RESULTS: There were documented fatal VAs in 29 (26.8%) patients during a mean follow-up time of 71.3 ± 30.9 months. Compared with the other groups, the fatal VA group had a higher incidence of the following: presence of MB (82.8 vs. 38%, p < 0.001), deep MB (62.1 vs. 6.3%, p < 0.001), very deep MB (24.1 vs. 0%, p < 0.001), long MB (65.5 vs. 11.4%, p < 0.001), presence of > 1 MB (17.2 vs. 0%, p = 0.001), and MB of the left anterior descending artery (79.3 vs. 17.7%, p < 0.001) . Sudden cardiac death (SCD) risk score (hazard ratio: 1.194; 95% CI: 1.071-1.330; p = 0.001) and presence of MB (hazard ratio: 3.815; 95% CI: 1.41-10.284; p = 0.008) were found to be independent predictors of fatal VAs in HCM patients. CONCLUSIONS: The current data suggest that the SCD risk score and presence of MB were independent risk factors for fatal VAs in patients with HCM. In addition to conventional risk factors, the coronary anatomical course can provide clinicians with valuable information when assessing the risk of fatal VAs in HCM patients.

An overlooked cause for reversible severe tricuspid regurgitation and pulmonary hypertension: Hibernating right ventricle.

Tricuspid regurgitation (TR) can occur due to many etiologies, including primary valve disease, left heart disease, annular dilatation in atrial fibrillation, or pulmonary hypertension (PH). Functional TR is caused by tricuspid annular dilatation in the setting of right ventricular remodeling. The right ventricle (RV) ischemia is an overlooked cause of functional TR which tends to diminish with an improvement in right heart functions. We present the case of a patient in whom functional TR significantly improved after percutaneous revascularization. We highlight that the ischemic RV can present with reversible functional TR or PH and emphasized the necessity of accurate detection of the etiology.

Real-life data regarding acute procedural success and 1-year clinical outcome of desolve bioresorbable scaffolds.

OBJECTIVES: We aimed to evaluate the peri-procedural success of DESolve bio-resorbable scaffolds (BRSs) and analyzed real-life data about major cardiac events during 1-year follow-up. BACKGROUND: There is little information about real-life data of DESolve BRS which is a novel stent technology offering various advantages over drug eluting stents and commonly used in daily cardiology practice. METHODS: We conducted this single-center and non-randomized cross-sectional study from June 2015 through August 2016 in Medipol University Department of Cardiology and included 117 patients undergoing single or multivessel percutaneous coronary interventions (PCI) with novolimus-eluting BRS devices (152 scaffolds) (Elixir Medical Corporation). Study end points were acute device and procedural success, scaffold thrombosis and major adverse cardiac event (MACE) rates of DESolve BRS. RESULTS: Device success was 96.7% and procedural success was 99.3%. We detected MACE rate as 0.9% while clinical-driven target lesion revascularization was performed in one patient. None of the patients experienced scaffold thrombosis or death. Peri-procedural complications were reported in three patients. CONCLUSIONS: High rates of successful scaffold implantations, low rates of peri-procedural complications, and major cardiac events in long-term suggest that DESolve scaffolds can safely and effectively be used in daily intervention practice by particularly experienced operators.

Assessment of repolarization abnormalities in baseline electrocardiograms of patients with myocarditis

Background/aim: Myocarditis in the acute phase usually presents with sinus tachycardia but many other arrhythmias might be seen as well. In this study we aimed to investigate repolarization abnormalities in baseline ECG of patients with myocarditis for the first time.Materials and methods: Thirty patients diagnosed with myocarditis and 25 healthy age-matched controls were included. Two different cardiologists measured corrected QT (QTc), QT dispersion (QTd), QT peak (QTp), T wave peak to T wave end (TpTe), TpTe/QT ratio, and TpTe/QTc ratio in 12-lead ECG.Results: When compared with the control group, QTp (P: 0.021), QT (P: 0.003), TpTe (P < 0.001), TpTe/QTc ratio (P < 0.001), and TpTe/QT ratio (P: 0.005) were significantly higher in patients with myocarditis. A comparison of receiver operating characteristic (ROC) curves was conducted using the Hanley and McNeil method. The area under the curve (AUC) of the electrocardiographic characteristics QT (AUC: 0.736; 95% CI [0.600-0.846]), QTP (AUC: 0.680; 95% CI [0.540-0.799]), and TpTe (AUC: 0.771; 95% CI [0.638-873]) and TpTe/QTc (AUC: 0.774; 95% CI [0.641-0.876]) and TpTe/QT (AUC: 0.726; 95% CI [0.589-0.838]) in myocarditis were not significantly different from each other but all of them were different from 0.5.Conclusion: Baseline ECGs of patients with myocarditis were associated with repolarization abnormalities. These novel findings may be one of the reasons underlying arrhythmic events in patients with myocarditis.

Evaluation of adult versus pediatric transesophageal echocardiography probe efficiency for guiding septal puncture during atrial fibrillation ablation.

PURPOSE: Transesophageal echocardiography (TEE) has a pivotal role in invasive cardiology practice in terms of guiding a variety of procedures. It is challenging to perform TEE examination with sedated patients due to difficulties in cooperation and positioning the patient properly, therefore the risk of complications is escalated. We aimed to assess the impact of pediatric TEE probe utilization on procedural success and complication rates; in comparison with conventional adult TEE probe. METHODS: Fifty-eight patients undergoing atrial fibrillation (AF) ablation with TEE guidance were enrolled and patients were grouped based on probe size: Group 1 (n = 35) included patients undergoing the procedure with adult TEE probe guidance and Group 2 (n = 23) included patients with pediatric TEE probe guidance. Procedural success, postprocedural odynophagia and periprocedural intra-oral bleeding frequency, number of intubation attempts, TEE imaging time, and midazolam doses for both groups were compared. RESULTS: Odynophagia frequency was significantly higher in Group 1 (25.7% [n = 9] vs. 0%, P = 0.008) besides oral mucosal bleeding was also higher in Group 1, although the difference did not reach statistical significance (5.7% [n = 2] vs. 0%, P = 0.513). Number of repeated attempts was lower in Group 2 (median, 1; range [3-1] vs. 1, [1-1], P = 0.038). Image resolutions and septal puncture success rates were similar for both groups. Total imaging time with TEE was significantly shorter in Group 2 (6.4 ± 1.8 min vs. 3.6 ± 0.9 min, P < 0.001). Midazolam dose was lower in Group 2 (7.0 ± 1.7 vs. 6.2 ± 1.7, P = 0.065). CONCLUSION: Using TEE probes with smaller size for guiding invasive percutaneous procedures performed in cardiac catheterization laboratory decreased TEE-associated complication rates and enhanced patient comfort without any negative effect on procedural success.

Non-surgical treatment of a right ventricle puncture during diagnostic pericardiocentesis.

Pericardiocentesis is a life-saving procedure performed in cardiac tamponade cases occurring in infective, inflammatory or malignancy conditions, or following percutaneous coronary intervention, cardiac device implantation or catheter ablation. In spite of advanced imaging methods, a substantial risk of complication persists. Emergent surgical intervention may be required, in particular during advancement of the catheter into the heart chambers or in cases of wall rupture. Furthermore, in all these cases, patients have a high risk of surgery because of existing comorbidities. This case presents a patient suspected of tuberculous pericarditis who underwent diagnostic pericardiocentesis complicated by right ventricular puncture. The catheter in the right ventricle was withdrawn via a second catheter placed in the pericardial cavity. Spontaneous blood control was established, and with no increase in pericardial effusion surgical intervention was not required. This method can be applied in certain conditions, including cardiac injury caused by pericardiocentesis or intracardiac manipulations, thus eliminating the need for high-risk surgical intervention.

Pregnancy in a Rare and Acquired Mitral Stenosis Different from Rheumatic Mitral Involvement: Mitral Ring Mismatch.

There is an increasing incidence of diagnosing both congenital and acquired heart valve diseases in women during pregnancy. Factors such as elevated rates of pregnancy, older maternal age, and coexisting conditions like diabetes, hypertension, and obesity contribute significantly to the symptomatic manifestation and detection of valvular heart diseases in women planning for pregnancy. Pregnancy induces cardiovascular changes across the maternal physiology, posing a heightened risk of morbidity and mortality, especially in women afflicted with valvular heart diseases. In this article, we present a case of a 25-year-old patient who underwent mitral ring annuloplasty surgery at the age of 9. Her echocardiography revealed a mismatch of the mitral ring during a follow-up examination at the age of 20. Despite neglecting further follow-ups, the patient became pregnant and presented to us at the 6th week of pregnancy. She underwent evaluations at the 6th, 10th, and 22nd weeks of pregnancy, as well as before delivery. Following the resumption of follow-up appointments, intervention planning was initiated during the postpartum period. This case exemplifies successful management, resulting in a healthy delivery after navigating through the pregnancy.

Turkish Real Life Atrial Fibrillation in Clinical Practice: TRAFFIC Study.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and is associated with an increased risk of thromboembolism, ischemic stroke, impaired quality of life, and mortality. The latest research that shows the prevalence and incidence of AF patients in Türkiye was the Turkish Adults' Heart Disease and Risk Factors study, which included 3,450 patients and collected data until 2006/07.The Turkish Real Life Atrial Fibrillation in Clinical Practice (TRAFFIC) study is planned to present current prevalence data, reveal the reflection of new treatment and risk approaches in our country, and develop new prediction models in terms of outcomes. METHODS: The TRAFFIC study is a national, prospective, multicenter, observational registry. The study aims to collect data from at least 1900 patients diagnosed with atrial fibrillation, with the participation of 40 centers from Türkiye. The following data will be collected from patients: baseline demographic characteristics, medical history, vital signs, symptoms of AF, ECG and echocardiographic findings, CHADS2-VASC2 and HAS-BLED (1-year risk of major bleeding) risk scores, interventional treatments, antithrombotic and antiarrhythmic medications, or other medications used by the patients. For patients who use warfarin, international normalized ratio levels will be monitored. Follow-up data will be collected at 6, 12, 18, and 24 months. Primary endpoints are defined as systemic embolism or major safety endpoints (major bleeding, clinically relevant nonmajor bleeding, and minor bleeding as defined by the International Society on Thrombosis and Hemostasis). The main secondary endpoints include major adverse cardiovascular events (systemic embolism, myocardial infarction, and cardiovascular death), all-cause mortality, and hospitalizations due to all causes or specific reasons. RESULTS: The results of the 12-month follow-up of the study are planned to be shared by the end of 2023. CONCLUSION: The TRAFFIC study will reveal the prevalence and incidence, demographic characteristics, and risk profiles of AF patients in Türkiye. Additionally, it will provide insights into how current treatments are reflected in this population. Furthermore, risk prediction modeling and risk scoring can be conducted for patients with AF.

Early Valve Thrombosis Management After Successful Transcatheter Tricuspid Valve-in-Valve Implantation.

Transcatheter tricuspid valve-in-valve implantation is a critical option in high risk bioprosthetic tricuspid valve dysfunction. In this case report, balloon-expandable transcatheter heart valve was implanted successfully into the tricuspid valve and early thrombosis was managed successfully. (Level of Difficulty: Intermediate.).

Contribution of Three-Dimensional Echocardiography Xplane Mode in the Evaluation of Semilunar Cusps: Two Different Case Reports.

Orthogonal-biplane imaging (X-plane) is relatively a new tooL and provides comprehensive information about mitral valve and left atrial appendage evaluation. On the other hand, X-plane method is a promising method in the diagnosis of semilunar valve pathologies. Below, we report 2 cases, in which X-plane method was used, in order to clarify diagnosis. Case 1: Case 1 was a 63-year-old male patient who was admitted to our clinic with dyspnea. Right ventricular dilatation and hypertrophy were assessed. In order to determine the exact reason for right ventricular pressure overload, the pulmonary valve was evaluated by X-plane, and a bicuspid pulmonary valve was represented. This patient underwent pulmonary valve percutaneous valvuloplasty. Case 2: Case 2 was a 48-year-old male patient who was admitted to our hospital with a history of cerebrovascular event. His initial transthoracic and transesophageal echocardiography showed a hyperechoic mobile mass on the non-coronary cusp. However, after X-plane was used to detect the aortic valve, it was the prolapsed part of the non-coronary cusp adjacent to the commissure. These 2 case reports demonstrated the efficacy of the X-plane method in the diagnosis of semilunar valve pathologies in daily practice.

The relation of right ventricular outflow tract measurements with in-hospital clinical outcomes after tricuspid valve surgery.

Right ventricular (RV) function is a determining factor for clinical outcomes in patients undergoing tricuspid valve surgery (TVS). Our aim was to investigate the importance of the function of the right ventricular outflow tract (RVOT), which is an important anatomical region of the RV, in patients underwent TVS. 104 patients who underwent TVS were analyzed retrospectively. Patients with previous cardiac surgery, congenital heart disease, or heart failure were excluded. The parasternal short-axis view at the level of the aortic root was used to measure RVOT dimensions and RVOT fractional shortening (RVOT-FS). The effect of RVOT diameter and function on major adverse cardiac events (MACE) after TVS was investigated. In our study, MACE, consisting of pacemaker implantation, acute kidney injury, postoperative atrial fibrillation and mortality, was developed at 44 (42.3%) patients.We compared the predictive performances of RVOT end-systolic (RVOTs) diameter, RVOT end-diastolic (RVOTd) diameter, RVOT-FS and RV diameters in prediction of MACE. The model including the RVOTs had higher AUC, R2 and likelihood ratio X2 values (0.775, 0.287 and 25.0, respectively) than RVOTd (0.770, 0.279 and 24.2, respectively) and RVOT-FS (0.750, 0.215 and 18.1, respectively). RVOT diameters showed better performance in predicting MACE than RV diameters. Moreover, there was statistically significant association between RVOTs, RVOTd and MACE (p value were 0.014 and 0.027, respectively), while no association between RVOT-FS and MACE (p value was 0.177). In summary, we determined that the RVOT diameters are important predictors for the in-hospital clinical outcomes of patients who underwent TVS.

Heavy Calcification of Left Atrium and Calcific Mass on Mitral Valve: An Unusual Presentation of Ankylosing Spondylitis.

Ankylosing spondylitis is a complex chronic disease that starts from the spine and sacroiliac joint, causes joint stiffness, and affects the quality of life. Aortic dilatation, aortic valve insufficiency, and heart block due to conduction system involvement are the leading accompanying cardiac pathologies. In this case report, we aimed to show a rare cardiac involvement of left atrial calcification, pericardial involvement, and formation of a calcified inflammatory mass that might be misdiagnosed as vegetation on the mitral valve in a late-stage ankylosing spondylitis patient, by using multimodality imaging and histopathological diagnosis.

A case of progressive dyspnea: Atrial septal device-related functional mitral regurgitation after myocardial infarction.

Transcatheter device closure is a common treatment option of atrial septal defect. Mitral regurgitation has been reported with comorbid mitral valve prolapse and atrial septal defect. However there is no consensus regarding the pathogenesis of mitral regurgitation after closure. We are reporting a patient with functional mitral regurgitation associated with both an oversize closure device and wall motion abnormality after inferior myocardial infarction.

Does patent foramen ovale presence procure favourable outcomes in patients with severe rheumatic mitral stenosis?

Mitral stenosis (MS) is tolerated for an extended period in patients with atrial septal defect (ASD) known as Lutembacher syndrome due to depressurizing effect. In a similar way, patients with patent foramen ovale (PFO) may have clinical benefits in severe MS. We aim to evaluate the clinical effects of PFO in rheumatic MS. Transthoracic and transesophageal echocardiography records of the patients with symptomatic severe MS were screened for the period between 2008 and 2019 in a single center. 320 symptomatic patients with severe MS were included and presence of PFO recorded. Left atrial appendix (LAA) thrombotic status was defined as clear, spontaneous echo contrast, and thrombus. Two different statistical models were used to determine the predictors of either smallest (mitral valve area) MVA at symptomatic presentation or more thrombogenic LAA. 34 patients had PFO. Multivariable ordinary least square model demonstrated that increase in systolic pulmonary arterial pressure, ejection fraction and presence of PFO were associated with smaller MVA on presentation. Multivariable proportional odds logistic regression model demonstrated that advanced age, increased left atrial diameter, absence of PFO were associated with more thrombotic status whereas larger MVA was associated with decreased thrombotic status in LAA. Presence of PFO in severe MS results in two clinical benefits as (i) being asymptomatic with smaller MVA and (ii) having less LAA thrombosis probably caused by depressurizing effect on the left atrial pressure. Our study could serve as an example for patient groups with expected symptomatic benefits from left atrium pressure offloading interventions.

Relationship between myocardial energy expenditure and postoperative ejection fraction in patients with severe mitral regurgitation.

OBJECTIVE: This prospective study aimed to investigate the myocardial energy metabolism in severe mitral regurgitation (MR) and explore its effect on postoperative differentiation of ejection fraction (EF). METHODS: A total of 85 patients with severe MR were prospectively enrolled from October 2018 to June 2019. During the study period, a total of 50 patients underwent mitral valve surgery and 49 patients were finally enrolled due to 1 missing data. Left ventricular function, circumferential end-systolic stress (cESS), and myocardial energy expenditure (MEE) were measured by transthoracic echocardiography preoperatively and 3 months after surgery. Patients were divided into 2 groups according to absolute difference of postoperative differentiation of EF. RESULTS: Nine patients underwent mitral valve repair and 40 underwent prosthetic valve replacement. Patients with reduced EF had higher MEE demonstrated with cESS and MEE. Negative correlation between preoperative EF and N-terminal pro-brain natriuretic peptide (NT-proBNP), cESS, MEEs, and MEEm and positive correlation between preoperative EF and effective regurgitant orifice area were found. Complications occurred in 12 patients during hospitalization. Basal NT-proBNP, left atrium (LA), and cESS were significantly higher in postoperatively decreased EF group. Taking into consideration the covariates of multiple logistic regression analysis, LA and cESS were found to be independent predictors of EF reduction postoperatively. CONCLUSION: Higher LA and cESS are independent predictors of postoperative EF reduction. Preoperative high end-systolic stress could predict postoperative EF reduction and hence could be helpful for determining the timing of mitral valve surgery. Although MEE was higher in postoperatively decreased EF group, it did not reach statistical significance.

Characterization, epidemiological profile and risk factors for clinical outcome of infective endocarditis from a tertiary care centre in Turkey.

Background: We aimed to investigate the clinical, laboratory, microbiological characteristics of IE in a single tertiary care centre in Turkey and to identify the factors associated with in-hospital mortality. Methods: A total of 155 consecutive adult patients (≥18 years) admitted to our single tertiary care hospital between 2009 and 2019 with definite infective endocarditis were retrospectively included in the study. Results: The mean age of the patients was 58 years. Among 155 endocarditis episodes, 60% involved prosthetic valves, 35.5% had native valve endocarditis (NVE) and 4.5% were device related. Prosthetic valve disease was the most frequent predisposing valve lesion followed by degenerative valvular disease. Vegetations were detected in 103 (66.5%) patients by transthoracic echocardiography and in 145 (93%) patients by transoesophageal echocardiography. The most commonly affected valve was the mitral valve in 84 (54.2%) patients, followed by 67 (43.2%) aortic valve. Staphylococci were the most frequent causative microorganisms isolated in both NVE (31.8%), prosthetic valve endocarditis (38.9%) and device related IE cases. At least one complication was present in 70 patients (45.2%). One hundred and eight patients underwent surgical therapy (69.7%). Age, syncope, heart failure, perforation, septic shock, renal failure, high red cell distribution width, atrial fibrillation, hypocalcaemia, pulmonary hypertension were associated with high mortality. Conclusions: We identified a 10-year presentation of IE in a referral centre in Turkey. Likely other series, we observed more staphylococcus endocarditis with the aging of the population. Surgery was associated with higher in-hospital survival. Age, syncope, perforation, septic shock were independent predictors of mortality.