An unusual complication after permanent pacemaker implantation: Methemoglobinemia.

Permanent pacemaker implantation (PPI) is usually a very safe procedure with a low complication risk. It is a relatively straightforward process carried out under local anesthetic. This case report presents an 80-year-old male patient who required a permanent pacemaker due to complete atrioventricular (AV) block, and who developed cyanosis and was diagnosed with methemoglobinemia after the pacemaker insertion procedure, in which the local anesthetic prilocaine was administered. To our knowledge, this is the first case in the literature to describe methemoglobinemia developing after PPI.

Transcatheter aortic valve implantation in the presence of hematologic malignancies.

OBJECTIVE: Cardiac surgery may be performed in patients with hematologic disorders, but carries an increased risk of morbidity. This series describes an experience of transcatheter aortic valve implantation (TAVI) in patients with hematologic malignancies, and highlights the technical considerations to be kept in mind. METHODS: Between June 2011 and April 2014, 133 consecutive high-risk patients with symptomatic severe aortic stenosis were treated with TAVI at our centre. Based on consensus among the local heart team, five patients with hematologic malignancies (myelodysplastic syndrome [2],chronic lymphocytic leukemia [2], Hodgkin lymphoma [1]) were considered high risk for surgery (Logistic EUROSCORE 17.2±14.0% and STS score 5.8±4.3%). Serial echocardiographic and clinical follow-ups were done pre- and post-procedure, at discharge, and at 1, 3, 6 and 12 months. RESULTS: Our procedural success rate was 80%. Two heart valves were implanted in one patient due to aortic embolization of the previous valve. Perforation of the right ventricle and cardiac tamponade occurred in the same patient. Mean blood transfusion requirement was 1.0±1.4 U (range: 0 to 3 U). Mean aortic valve gradient was reduced from baseline to 9.2±3.27 mmHg, and the effective orifice area was significantly increased to 1.96±0.29 cm2. Paravalvular aortic regurgitation (AR) was absent-mild in all the patients. CONCLUSION: This present series demonstrates that TAVI with a balloon-expandable valve can be performed safely and effectively and is technically feasible in high-risk patients with hematologic malignancies.

Coronary Slow Flow is Associated with Depression and Anxiety.

BACKGROUND: There is an established relationship between depression/anxiety disorders and cardiovascular morbidity and mortality which has been previously documented. However, there has been no study evaluating coronary slow flow in association with depression and anxiety. METHODS AND RESULTS: A total of consecutive 90 patients were included in the study. All patients completed scoring scales for depression [Hamilton Rating Scale for Depression (HAMD)] and anxiety (STAI-1, State anxiety subscale of State-Trait Anxiety Inventory; STAI-2, Trait anxiety subscale of State-Trait Anxiety Inventory). Thereafter, they underwent selective coronary angiography and 2 groups were formed: coronary slow flow (n = 42), and normal coronary flow (n = 48). The two groups had comparable baseline characteristics. However, significant differences were found between coronary slow flow and normal coronary flow groups regarding depression (13.1 ± 8.2 and 6.9 ± 6.7, p < 0.001 for HAMD, respectively) and anxiety (46.2 ± 15.0 vs. 32.6 ± 9.9, p < 0.001 for STAI-1 and 51.0 ± 16.7 vs. 43.0 ± 10.7, p = 0.009 for STAI-2, respectively) scores. There were also significant positive correlations between depression/anxiety scores and TIMI frame counts of all major epicardial coronary arteries. In addition, after adjustment for smoking, hypertension, scoring scales, and the presence of depressive mood, all scoring scales and depressive mood were found to be independent risk factors for coronary slow flow in multivariable logistic regression analysis. CONCLUSIONS: Significant association was found among coronary slow flow, depression/anxiety scores and depressive mood. KEY WORDS: Anxiety; Coronary slow flow; Depression; Scale.

The evaluation of endothelial functions in patients with celiac disease.

AIM: Celiac disease is characterized by malabsorption resulting from inflammatory injury to the mucosa of the small intestine after the ingestion of wheat gluten or related rye and barley proteins. This study aimed to identify individuals who are at risk of heart failure and increased risk for cardiovascular events by evaluating endothelial function in patients with celiac disease. MATERIALS AND METHODS: The study included 36 patients with celiac disease and 35 healthy volunteers. After all routine laboratory examination, left ventricular functions were evaluated with standard two-dimensional, M-mode conventional Doppler methods. Then, flow-mediated dilatation and nitroglycerin-dependent dilatation tests on brachial artery were performed to all patients and controls. RESULTS: A total of 36 celiac patients and 35 healthy volunteers were included in the study. The brachial artery diameter at baseline was similar between both groups. Measured brachial artery diameter after hyperemia was 30.19 ± 4.47 mm in celiac patients and 32.35 ± 3.77 mm in the control group. Differences between two groups were statistically significant (P = 0.031). Flow-mediated vasodilatation was lower in celiac patients compared with in controls (10.61 ± 2.64% vs 13.09 ± 2.9%; P = 0.0003). Measured endothelium-independent vasodilatation in the brachial artery before and after nitroglycerin was similar between both groups (P = 0.09 and P = 0.07, respectively). CONCLUSION: This research which aimed to evaluate endothelial dysfunction in patients with celiac disease is the first in the literature. As a result of this study, we found endothelial dysfunction at the macrovascular level in celiac patients.

A rare cause of atrial fibrillation: mad honey intoxication.

BACKGROUND: Mad honey intoxication occurs after ingestion of honey containing grayanotoxin. CASE REPORT: We report the case of a 36-year-old man who ingested mad honey and developed atrial fibrillation. DISCUSSION: Mad honey intoxication is often characterized by symptoms such as hypotension, bradycardia, and syncope. Patients may also experience gastrointestinal, neurologic, and cardiovascular symptoms due to intoxication. Cardiac rhythm abnormalities, including sinus bradycardia, atrioventricular blocks, and nodal rhythms, also may be observed. To our knowledge, this is the first case report of a 36-year old man developing atrial fibrillation with a slow ventricular response after mad honey ingestion.

Baseline Anemia Is an Independent Predictor of Long-Term Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation.

This study aimed to investigate the relationship between baseline anemia and long-term mortality in a single-center retrospective study involving patients undergoing transcatheter aortic valve implantation (TAVI). The study population included 412 consecutive patients undergoing TAVI at a center for severe aortic valve stenosis between August 2011 and November 2018. The primary end point of the study was all-cause mortality. Baseline anemia was present in 50% of our study cohort. During the median follow-up of 29 months, all-cause mortality was observed in 40.3% of the whole study population and was more frequently observed in the anemic group compared with the nonanemic group (53.5% vs 27.1%, P < .001, respectively). Cox-regression analysis revealed that Society of Thoracic Surgeons Predicted Risk of Mortality score, previous stroke, pericardial tamponade, and neutrophil-lymphocyte ratio count are independent predictors of long-term mortality after TAVI. Additionally, the presence of anemia at baseline was an independent predictor of long-term mortality with a 2.3-fold difference in the anemic group compared with the nonanemic group (hazard ratio: 2.31, 95% CI: 1.59-3.37, P < .001). Baseline anemia was observed in half of our patient population undergoing TAVI, and baseline anemia was found to be an independent predictor of long-term mortality after TAVI.

Evaluation of left ventricle function by strain imaging in patients with familial Mediterranean fever.

AIM: Familial Mediterranean Fever (FMF) is a hereditary inflammatory disease characterized by recurrent fever and serositis. We aimed to evaluate cardiac involvement in FMF patients by using strain and strain rate echocardiographic imaging method in this study. MATERIALS AND METHODS: Echocardiographic evaluation was performed in 23 FMF patients and 22 healthy controls. FMF diagnosis was based on Tell-Hashomer diagnostic criteria. Conventional echocardiography, tissue Doppler echocardiography and longitudinal two-dimensional (2D) strain and strain rate imaging were performed in patient and control groups. RESULTS: There were no significant differences between patient and control groups in terms of 2D, M-mode, conventional Doppler and tissue Doppler velocities. Left ventricle strain value was significantly lower in five out of eight segments in FMF patients than controls and left ventricle strain rate value was significantly lower in three out of eight segments in FMF patients than controls. Mean left ventricle strain value was significantly lower in FMF patients than controls (-21.1 ± 2.2% vs. -23.8 ± 2.2%; P < 0.001). No significant difference was noted between FMF patients and controls in mean left ventricle strain rate value (-1.61 ± 0.23 vs. -1.58 ± 0.21; P = 0.48). CONCLUSION: We have shown that although conventional echocardiography and tissue Doppler velocity data were similar, strain, strain rate values were significantly lower in FMF patients than controls. We know that strain and strain rate imaging method might be useful for evaluating subclinical cardiac involvement in case of normal conventional and tissue Doppler velocity data in patients with FMF.

Case report: hip septic arthritis and abcess after diagnostic coronary angiography.

Coronary angiography is an invasive procedure which can have some complications. Septic arthritis and abscess after coronary angiography are extremely rare. In this case, a 49-year-old-man presented to our hospital with non-ST-segment elevation myocardial infarction. After coronary angiography, he had right leg weakness, femoral palsy, inguinal pain, but there was no bleeding or hematoma. The cause was right hip septic arthritis and abscess.

Medical treatment of mural left ventricular endocarditis mass: a case report.

Infective endocarditis (IE) is an inflammatory disease of the endocardium, with a high morbidity and mortality, particularly when it progresses with predisposing conditions and complications. Embolic events induced by mural cardiac vegetations are a common and life-threatening complication of IE. Herein, we present a first case with left ventricular IE and a giant vegetation causing multiple emboli.

The relationship between coronary slow flow phenomenon and coronary calcium score.

AIM: Coronary slow flow phenomenon (CSFP) is an angiographic finding characterized by delayed distal vessel opacification without any significant epicardial coronary artery disease. Several studies have suggested that CSFP might be a form of atherosclerosis. The present study was aimed to investigate the relationship between CSFP and coronary artery calcification, which is one of the clear-cut indicators of coronary atherosclerotic plaque, by using computerized tomography. METHOD: Fifty-five patients were included in the study. The coronary arteries of all patients were shown by angiography to be normal. Coronary slow flow (CSF) patterns were evaluated by the thrombolysis in myocardial infarction frame count (TFC) method. Patients with normal coronary arteries and CSF were allocated into the CSF group, and patients with normal coronary arteries and normal coronary flow were allocated into the control group. Coronary artery calcium (CAC) score was measured in 28 patients with CSF and in 27 controls by 64-slice computerized tomography. RESULTS: The CSF and control groups were similar with respect to age, gender, smoking status, presence of hypertension and diabetes mellitus, cholesterol profiles, and Framingham risk scores (p>0.05). The CSF and control groups were not significantly different with respect to CAC score (p>0.05). Sub-group analysis of cardiac risk factors in patients with or without coronary artery calcification revealed that advanced age and low high density lipoprotein (HDL) levels were significantly associated with coronary artery calcification. There wasn't any relationship between coronary slow flow and cardiac risk factors or coronary calcium scores. CONCLUSION: In the present study, no association was found between the CSFP and calcified atherosclerosis. Additionally, it was demonstrated that, among the cardiac risk factors, advanced age and low HDL levels were associated with coronary artery calcification.

Late stent thrombosis after paclitaxel-eluting stent placement in a patient with essential thrombocytosis.

We report on a case of late stent thrombosis after drug-eluting stent placement in a patient with essential thrombocytosis. A 51-year-old male patient with a three-month history of paclitaxel-eluting stent placement to the left anterior descending artery presented with a complaint of severe retrosternal chest pain. A high platelet count (1,063,000/mm3) was detected two months prior to presentation, which was interpreted as essential thrombocytosis. He was on standard dual antiplatelet therapy (aspirin and clopidogrel). The electrocardiogram showed ST-segment elevation in leads V1-V6. Emergent coronary angiography revealed thrombotic total occlusion at the location of the paclitaxel-eluting stent. Balloon angioplasty was performed yielding a satisfactory result and TIMI 3 flow. Following the procedure, there was no chest pain. His platelet count was 388,000/mm3. He was discharged on medical therapy following an uneventful hospital course. Patients with essential thrombocytosis may not be eligible for drug-eluting stent placement.

Endothelial function in normotensive men with obstructive sleep apnea before and 6 months after CPAP treatment.

STUDY OBJECTIVES: To evaluate endothelium-dependent flow-mediated dilation (FMD) and endothelium-independent nitroglycerin (NTG)-induced dilation of the brachial artery with Doppler ultrasound in patients with obstructive sleep apnea (OSA) and impact of six months of continuous positive airway pressure (CPAP) treatment. DESIGN: A prospective, controlled, observational study. SETTING: Single-site, clinic-based. PATIENTS: Twenty-nine normotensive men with OSA (apnea-hypopnea index [AHI], mean +/- SD, 60.4 +/- 22.1-h), and 17 men without OSA (AHI 2.5 +/- 0.6-h). INTERVENTIONS: Six months of CPAP therapy in OSA patients. MEASUREMENTS AND RESULTS: FMD was lower in patients with OSA compared with in controls (7.19 +/- 1.78% vs 10.93 +/- 2.59%; P < 0.001) while NTG-induced vasodilation was similar in both groups (13.75 +/- 1.01% vs 14.25 +/- 1.83%; n.s.). An inverse relationship was found between FMD and AHI adjusted for age and body mass index (BMI) (beta = - 0.05, P < 0.001). Following 6 months of CPAP treatment in the OSA group, FMD was increased from 7.38 +/- 2.06% to 10.45 +/- 1.68; P = 0.001) in 20 patients compliant with the device whereas the corresponding values did not change in the non-user group (7.08 +/- 1.50% vs 7.26 +/- 1.01%). No significant changes were observed regarding the NTG-induced vasodilation after CPAP compared with the baseline values. CONCLUSIONS: Our results confirm the previous reports suggesting impaired endothelium-dependent FMD in OSA, and additionally document the sustained improvement in endothelial function after 6 months of CPAP treatment in complaint patients.

Effect of continuous positive airway pressure therapy on aortic stiffness in patients with obstructive sleep apnea syndrome.

OBJECTIVE: The most significant complications seen in patients with obstructive sleep apnea syndrome (OSAS) are associated with the cardiovascular system. The present study assessed aortic stiffness in patients with OSAS and evaluated the effect of continuous positive airway pressure (CPAP) therapy on aortic stiffness. METHOD: Twenty-four patients with newly diagnosed, previously untreated, moderate or severe OSAS (apnea-hypopnea index > 15) and a control group of 17 healthy patients were included in the study. M-mode recordings of the ascending aorta were taken from the parasternal long axis by echocardiograhy, and systolic and diastolic diameters of the aorta were measured. Aortic elastic parameters, aortic strain, and distensibility were calculated. Measurements were repeated after 6 months of CPAP therapy in patients with OSAS and were compared with baseline values. RESULTS: In patients with OSAS, compared with the control group, aortic strain (6.7%+/- 2.1% vs. 12.4%+/- 3.1%; P < 0.001) and aortic distensibility (2.8 +/- 0.9 x 10(-6) cm(2) dyn(-1) vs. 5.5 +/- 1.7 x 10(-6) cm(2) dyn(-1); P < 0.001) were evidently lower, and there was a significant correlation between aortic elastic parameters and AHI. After a 6-month course of CPAP therapy, significant increases were observed in aortic strain (6.1%+/- 1.5% vs. 7.3%+/- 1.7%; P < 0.001) and aortic distensibility (2.5 +/- 0.7 x 10(-6) cm(2) dyn(-1) vs. 3.1 +/- 0.9 x 10(-6) cm(2) dyn(-1); P < 0.001) in patients with OSAS. CONCLUSION: Aortic strain and distensibility were lower in patients with OSAS than in control patients, and CPAP treatment provided improvement in aortic elastic parameters.

Effects of continuous positive airway pressure therapy on right ventricular function assessment by tissue Doppler imaging in patients with obstructive sleep apnea syndrome.

OBJECTIVES: The effects of continuous positive airway pressure (CPAP) therapy on right ventricular (RV) function in patients with obstructive sleep apnea syndrome (OSAS) has not been previously studied by tissue Doppler imaging (TDI). The aim of this study was to assess RV function using TDI in patients with OSAS before and after CPAP therapy. METHODS: Twenty-eight patients with newly diagnosed OSAS in the absence of any confounding factors and 18 controls were included in this study. The peak systolic velocity (S'm), early (E'm) and late (A'm) diastolic myocardial peak velocities at tricuspid lateral annulus, isovolumic acceleration (IVA), myocardial precontraction time (PCT'm), myocardial contraction time (CT'm), and myocardial relaxation time (RT'm) were measured. All echocardiographic parameters were calculated 6 months after CPAP therapy. RESULTS: The RV diastolic parameters such as E'm velocity and E'm-to-A'm ratio were significantly lower, RT'm was significantly prolonged, A'm velocity was similar in patients with OSAS compared to controls; and the RV systolic parameters such as IVA and CT'm were significantly lower and S'm was similar in patients with OSAS compared to controls. At the end of the treatment, 20 of 28 patients were compliant with CPAP therapy. E'm velocity, E'm-to-A'm ratio, IVA, and CT'm increased, PCT'm, PCT'm-to-CT'm ratio, and RT'm decreased significantly after therapy, whereas S'm velocity and A'm velocity did not change after CPAP treatment in the compliant patients. CONCLUSION: OSAS is associated with RV systolic and diastolic dysfunction, and 6 months of CPAP therapy improves the RV systolic and diastolic dysfunction.

[Obstructive sleep apnea syndrome and cardiac arrhythmias]. / Obstrüktif uyku apnesi sendromu ve kardiyak aritmi.

Obstructive sleep apnea syndrome (OSAS) refers to recurring episodes of upper respiratory track obstruction and frequent decreases in arterial oxygen saturation due to repetitive occlusions of the posterior pharynx during sleep. Its prevalence in adult population is 4% in men and 2% in women. The most important causes of morbidity and mortality in affected patients are traffic accidents and cardiovascular complications including systemic arterial hypertension, coronary artery disease, congestive heart failure, and cardiac arrhythmias. The initial phases of apnea are associated with a transient increase in the parasympathetic activity resulting in bradyarrhythmias, followed by tachycardias due to increased sympathetic activity and arousal after the end of apnea episodes. The most frequent arrhythmia in OSAS is cyclic variation of heart rate. Most of the arrhythmias seen in OSAS are secondary to OSAS and disappear with OSAS treatment, without any electrophysiological conduction system abnormalities.

Prosthetic valve endocarditis 7 months after transcatheter aortic valve implantation diagnosed with 3D TEE.

Transcatheter aortic valve implantation (TAVI) was introduced as an alternative treatment for patients with severe symptomatic aortic stenosis for whom surgery would be high-risk. Prosthetic aortic valve endocarditis is a serious complication of surgical AVR (SAVR) with high morbidity and mortality. According to recent cases, post-TAVI prosthetic valve endocarditis (PVE) seems to occur very rarely. We present the case of a 75-year-old woman who underwent TAVI (Edwards Saphien XT) with an uneventful postoperative stay. She was diagnosed with endocarditis using three dimensional (3D) echocardiography on the TAVI device 7 months later and she subsequently underwent surgical aortic valve replacement. Little experience of the interpretation of transoesophageal echocardiography (TEE) and the clinical course and effectiveness of treatment strategies in post-TAVI endocarditis exists. We report a case of PVE in a TAVI patient which was diagnosed with three-dimensional transoesophageal echocardiography (3DTEE).

Evaluation of CA125 and NT-proBNP values in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a minimally invasive, emerging therapy in surgically high risk, or inoperable patients. Parameters used for risk classification have some deficiencies in the selection of patients. The objective of this study is to evaluate the impact of TAVI on carbohydrate antigen 125 (CA125) and N-Terminal pro Brain-type Natriuretic Peptide (NT-proBNP) as biomarkers that have been used frequently in recent years, and also the relationship of these biomarkers to prognosis. METHODS & RESULTS: Transcatheter aortic valve implantation was practiced on 31 patients in this study. Then, CA125 and NT-proBNP levels studied in patients prior to and after the TAVI were evaluated. The patients were also grouped in accordance with their left ventricular ejection fraction (LVEF) and CA125 levels (LVEF ≥ 40% and < 40%; CA125 ≤ 35 U/L and > 35 U/L). The TAVI operation was successfully performed in all patients. There was no in-hospital mortality and substantial improvement in functional capacity was detected at follow ups. In addition, a statistically significant decrease was detected in post-TAVI CA125 and NT-proBNP levels of all patients (CA125 83.8 ± 18.1 U/L vs. 64.3 ± 14.2 U/L, P = 0.008; NT-proBNP: 4633.6 ± 627.6 pg/mL vs. 2866.3 ± 536.8 pg/mL, P < 0.001). In groups divided according to the CA125 levels, there was also statistically significant post-TAVI decline in CA125 levels. Within CA125 > 35 U/L and LVEF < 40% groups, the permanent need for a pacemaker was required in one (3.2%) patient and mortality was observed in two (6.4%) patients after TAVI at follow up. CONCLUSIONS: The results show that TAVI can be performed effectively and reliably in patients with high baseline levels of CA125 and NT-proBNP. These biomarkers are reduced substantially with TAVI, while high biomarker levels are associated with undesired events, and certainly, these biomarkers can be used for risk classifications in patient selection for TAVI.

Transfemoral aortic valve implantation in severe aortic stenosis patients with prior mitral valve prosthesis.

INTRODUCTION: Transcatheter aortic valve implantation for severe symptomatic aortic stenosis in patients with a previous mitral valve prosthesis is technically challenging, and pre-procedural comprehensive assessment of these patients before transcatheter aortic valve implantation is vital for an uncomplicated and successful procedure. AIM: We want to share our experience with transcatheter aortic valve implantation in patients with a preexisting functional mitral valve prosthesis and describe a series of important technical and pre-procedural details. MATERIAL AND METHODS: At our center, 135 patients with symptomatic severe aortic stenosis were treated with transcatheter aortic valve implantation. Six of them with a preexisting mitral valve prosthesis received an Edwards SAPIEN XT valve through the transfemoral route. RESULTS: Transcatheter aortic valve implantation was performed successfully in all 6 patients without any deformation of the cobalt-chromium/steel stents of the aortic valve bioprosthesis. Also no distortion or malfunction in the mitral valve prosthesis was observed after the procedure. There were no complications during the hospitalization period. Post-procedural echocardiography revealed no or mild aortic paravalvular regurgitation and normal valve function in all the patients. In addition, serial echocardiographic examination demonstrated that both the stability and function of the aortic and mitral prosthetic valves were normal without any deterioration in the gradients and the degree of the regurgitation at long-term follow-ups. CONCLUSIONS: Our experience confirms that transcatheter aortic valve implantation is technically feasible in patients with previous mitral valve replacement but comprehensive evaluation of patients by multimodal imaging techniques such as transesophageal echocardiography and multislice computed tomography is mandatory for a successful and safe procedure.

Impact of transcatheter aortic valve implantation in patients with reduced ejection fraction.

BACKGROUND: Aortic stenosis increases with age. According to guidelines, left ventricular systolic dysfunction is an indication for aortic valve replacement, even in asymptomatic patients. There is no clear data on the application of transcatheter aortic valve implantation (TAVI), which is a method showing continuous improvement in recent years, in patients with reduced ejection fraction (REF) having a poor prognosis for surgical aortic valve replacement. We therefore aimed to investigate the effect of TAVI on left ventricular ejection fraction (LVEF) and also its efficacy and safety in patients with REF. METHODS AND RESULTS: The study included 104 patients who underwent transfemoral TAVI in our clinic. The patients were divided into two groups: LVEF ≤ 45% (REF group, n = 28) and LVEF > 45% (preserved ejection fraction [PEF] group, n = 76). Follow-up measurements were performed at baseline, discharge, 1st, 6th and 12th months. No statistical difference was found between the groups with respect to complications and mortality rates. A statistically significant difference was detected in LVEF after TAVI, either in all patients (53.9 ± 14.6, 57.0 ± 11.4, 59.4 ± 8.4, 60.4 ± 6.8, 63.2 ± 3.9, respectively, at baseline, discharge, 1st, 6th and 12th months, p < 0.001) or in the groups separately. A statistically significant increase in LVEF (p < 0.001) was determined at discharge, 1st, 6th and 12th months, whereas LVEF increased in all follow-ups of the PEF group, however this elevation reached a statistical significance only at the 1st month (p = 0.04). CONCLUSIONS: Our study has shown the positive effect of TAVI on LVEF and its effective and safe applicability in patients with REF.