Association of CHA2DS2-VASc score with thrombus burden in patients with acute myocardial infarction undergoing SVG-PCI.

BACKGROUND: The rate of saphenous vein graft (SVG) occlusion within the first year of bypass graft surgery is 15%. The CHA2DS2-VASc score is used to predict the risk of thromboembolic events in patients with nonvalvular atrial fibrillation. We aimed to evaluate the predictive role of the CHA2DS2-VASc score in the estimation of intracoronary thrombus burden in patients with acute myocardial infarction (AMI) who underwent SVG-PCI. METHODS: We retrospectively evaluated 221 patients who were admitted with AMI and underwent PCI of SVGs at the Department of Cardiology in the Turkiye Yuksek Ihtisas Education and Research Hospital between 2012 and 2018. The study population was divided into two groups according to their Thrombolysis in Myocardial Infarction (TIMI) thrombus grade: low thrombus burden (LTB; TIMI 0-3) and high thrombus burden (HTB; TIMI 4 and 5). RESULTS: The study included 221 patients with a mean age of 63.3 ± 6.7 years. The patients with HTB had significantly higher CHA2DS2-VASc scores (p < 0.001) compared with LTB patients. Univariate and multivariate regression analysis demonstrated that both CHA2DS2-VASc score (OR: 1.573, 95% CI: 1.153-2.147, p = 0.004) as a continuous variable and a binary cut-off level of the CHA2DS2-VASc score > 3 (OR: 3.876, 95% CI: 1.705-8.808, p = 0.001) were significantly associated with HTB. The ability of the CHA2DS2-VASc score to predict HTB burden was evaluated by receiver-operating characteristics analysis curve analysis. The optimum cut-off value of the CHA2DS2-VASc score for predicting HTB was 3 (with a sensitivity of 67.9% and a specificity of 69.3%) according to the Youden index. CONCLUSION: The CHA2DS2-VASc score can be used as an easy practical tool to predict HTB in AMI patients undergoing SVG-PCI.

Correction to: A child with bilateral multiple renal cysts presenting with ascites and pleural effusion: answers.

The original version of this article unfortunately contained a mistake. The answer to question 3 was presented incorrectly. The correct answer is given below.

Comparison of the predictive accuracy of four different ECG algorithms in identification of true ablation site for the idiopathic right ventricular outflow tract tachycardias.

BACKGROUND: We aimed to investigate the accuracy of four algorithms in prediction of right ventricular outflow tract (RVOT) tachycardias in patients who successfully underwent radiofrequency catheter ablation. METHODS: Four algorithms; two with easy-applicability and having a memorable design (Dixit and Joshi), and two with more complex and detailed design (Ito and Zhang) were compared according to the predictive accuracy. RESULTS: Among 99 patients (mean age 36.5 ± 8.5 years, 39.4% male), there were 51 (51.5%) septal-located and 48 (48.5%) free-wall located RVOT tachycardia. Comparison of the predictive accuracy of the algorithms showed that Zhang (91.9%) was the best algorithm for prediction of either septal or free-wall located tachycardia. The second best algorithm was the Ito (77.7%) compared to Dixit (75.8%) and Joshi (70.7%). CONCLUSION: In patients with RVOT tachycardia, algorithms with a detailed design may predict the arrhythmia location better than the easy-applicable algorithms.

Predictors of Impaired Reperfusion after Percutaneous Coronary Intervention in Patients with In-Hospital Acute Stent Thrombosis: A Retrospective Analyses of 5 Years of Data.

BACKGROUND: Acute stent thrombosis (STh) is a rare complication of percutaneous coronary intervention (PCI) and is associated with a high-risk of reperfusion failure. However, data focusing on risk factors of reperfusion failure in patients undergoing repeat PCI for treatment of STh remains inadequate. METHODS: A total of 8815 patients who underwent PCI with stent implantation from January 2009 to December 2013 were retrospectively reviewed. Among those cases, patients that presented with acute STh and underwent a repeat PCI for acute STh were identified. RESULTS: There were 108 patients who underwent repeat PCI for the treatment of in-hospital acute STh that were retrospectively analyzed. Of these study subjects, 21 (25%) had thrombolysis in myocardial infarction (TIMI) flow < 3 after repeat PCI. The median value of pain-to-balloon time was 40 minutes in the TIMI < 3 group, 35 minutes in the TIMI = 3 group (p < 0.001), and the first PCI-to-stent thrombosis time was also longer in the TIMI < 3 group (10 hours vs. 2.5 hours, p = 0.001). When patients were evaluated according to PCI time, the percentage of patients with TIMI < 3 was significantly higher in the night period compared to the daytime period (46.4% vs. 17.5 %, p = 0.002). In the multivariable logistic regression analysis, stent length [odds ratio (OR) = 1.18, 95% confidence interval (CI) 1.008-1.38] and pain-to- balloon time (OR = 1.28, 95% CI, 1.06-1.54) were the only independent predictors of failed reperfusion. CONCLUSIONS: Baseline stent length and pain-to-balloon time were associated with reperfusion failure in PCI for STh. Moreover, TIMI flow grade showed a circadian variation.

The Association between CHA2DS2-VASc Score and Mortality in Patients with Heart Failure with Reduced Ejection Fraction.

BACKGROUND: Heart failure (HF) is associated with significant mortality and morbidity. Therefore, identifying high-risk patients may optimize treatment for HF patients and reduce adverse events. The aim of this study was to assess the role of the CHA2DS2-VASc score to predict mortality in patients with reduced left ventricular ejection fraction (LVEF). METHODS: A total of 106 patients with reduced LVEF were enrolled in this study. All patients completed a one-year follow-up, and a CHA2DS2-VASc score was calculated for each patient. RESULTS: Twenty-one patients (19.8%) died during the 1-year follow-up. We found that baseline functional status, CHA2DS2-VASc score, brain natriuretic peptide, blood urea and hemoglobin levels were associated with mortality. In the multivariate analysis, CHA2DS2-VASc score and functional capacity were the only predictors of 1-year mortality. CONCLUSIONS: Use of the CHA2DS2-VASc score appears to be feasible for risk stratification and mortality prediction in patients with reduced LVEF.

Usefulness of the Macruz Index for Predicting Successful Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis.

OBJECTIVE: The aim of this study was to determine whether the Macruz index (P/P-R segment) could predict the severity of valvular involvement and the success of percutaneous mitral balloon valvuloplasty (PMBV) in patients with mitral stenosis (MS). SUBJECTS AND METHODS: Sixty-one patients with MS eligible for PMBV and 72 healthy subjects (61 females and 11 males) with sinus rhythm were enrolled into this study. PMBV was performed in all patients using a percutaneous transseptal antegrade approach and a multitrack balloon technique. The P/P-R segment ratio and echocardiographic variables were measured before and 48-72 h after the procedure. The optimal cutoff point for differences in the Macruz index to determine clinical success was evaluated by receiver operating characteristic analysis by calculating the area under the curve as giving the maximum sum of sensitivity and specificity for the significant test. RESULTS: In the patient group (mean age 42.9 ± 11.1 years), the preprocedural Macruz index was significantly higher than in the control group (2.79 ± 1.03 vs. 1.29 ± 0.11; p < 0.001). In the successful-procedure group (n = 53), the mean postindex value was significantly lower (2.12 ± 0.71 vs. 2.81 ± 1.0, p = 0.020), and the decrease in the Macruz index was significantly higher than in the unsuccessful-procedure group (p = 0.007). An index decrease of 0.105 was the best cutoff value to distinguish the successful-PMBV group from the unsuccessful- PMBV group (area under the curve = 0.888, 95% confidence interval 0.788-0.988, p < 0.001). CONCLUSION: The Macruz index was significantly higher in patients with MS compared to healthy subjects. A greater decrease in the Macruz index was associated with a successful PMBV.

Increased Platelet-to-Lymphocyte Ratios and Low Relative Lymphocyte Counts Predict Appropriate Shocks in Heart Failure Patients with ICDs.

BACKGROUND: Platelet-to-lymphocyte ratio (PLR) and relative lymphocyte count (L%) are commonly available tests that can be obtained from complete blood count. The aim of this study was to investigate the association between appropriate defibrillator therapy and PLR, and whether decreased lymphocyte count may predict appropriate implantable cardioverter defibrillator (ICD) shocks in heart failure (HF) patients. METHODS: A total of 147 patients with ischemic or non-ischemic HF who underwent ICD implantation for primary prevention were enrolled in this study. Peripheral venous blood samples were drawn on the same day as ICD implantation. White blood cell counts with differentials, red blood cell indices, and platelet counts were calculated with an automated blood cell counter. All patients were evaluated according to the presence of appropriate ICD therapy. RESULTS: Baseline ejection fraction was significantly lower in the appropriate shock received group (p = 0.040). Median PLR was significantly higher and L% was significantly lower in the appropriate shock received group (p < 0.001). In both ischemic and non-ischemic HF groups, median L% was significantly lower in the appropriate shock received group (p < 0.001; p = 0.006, respectively). In multivariable logistic regression analysis, only L% showed a strong association with appropriate shock therapy (p < 0.001). CONCLUSIONS: Higher PLRs are related to appropriate shocks in patients that received ICD with lower EF. Furthermore, decreased L% is independently associated with appropriate shocks in HF.

Usefulness of notched duration to predict response to cardiac resynchronization therapy.

OBJECTIVES: The presence of notches in the biventricular paced QRS complex (BiP-QRS) from the posterolateral cardiac vein displays delays in the activation of the left ventricle and may consequently be linked with longer times of stimulus conduction. Our objective was to determine the relationship between the notch duration ≥ 0.1 mV in the BiP-QRS and the effectiveness of cardiac resynchronization therapy (CRT). DESIGN: A total of 210 patients, who underwent de novo CRT implantation previously and had ≥ 1 follow-up between August 2009 and February 2014, were enrolled in the study. Echocardiographic response to CRT was defined as "an increase of ≥ 5% in ejection fraction" and clinical response to CRT was defined as "an improvement ≥ 1 in New York Heart Association class without heart failure hospitalization after 6 months of CRT implantation." RESULTS: At a mean follow-up of 9.2 ± 2.1 months, 142 patients (67%) were classified as responders to CRT. BiP-QRS duration was significantly longer among non-responders compared with responders (p = 0.036). More of the non-responders have notched in their BiP-QRS than responders (63% vs. 40%, p = 0.002). Median duration of notch was significantly higher among non-responders (80 ms vs. 67.5 ms, p = 0.041). Notch duration > 67.5 ms was associated with 2.8 times higher non-response to therapy (odds ratio: 2.8; 95% confidence interval: 1.075-7.588, p = 0.035). CONCLUSIONS: Patients with notch duration greater than 67.5 ms are associated with poor response to CRT. Notch duration > 67.5 ms predicts non-response to therapy with 50.0% specificity and 72.1% sensitivity.

Predictive Value of Resting Fractional Flow Reserve and Atherogenic Index of Plasma for Evaluation of Physiologically Significant Coronary Artery Lesions.

This study aimed to assess the relationship between the atherogenic index of plasma (AIP) and resting distal-to-aortic pressure ratio (Pd/Pa) in patients with intermediate coronary artery stenosis. This retrospective study included 802 chronic coronary syndrome patients with intermediate coronary artery stenosis who underwent fractional flow reserve (FFR) measurement. The resting Pd/Pa showed a significant negative correlation with AIP (rho= -.205, p < .001). When final FFR was divided into three tertiles (≤80, 81-89, ≥90), resting Pd/Pa was significantly lower, and AIP was markedly higher in the lower final FFR tertiles (both AIP and resting Pd/Pa differed significantly across the all three tertiles, p < .001). Furthermore, functionally significant stenosis independent predictors in multivariate analyses were AIP and resting Pd/Pa (p = .010 and p < .001, respectively). We observed for the first time an increase in AIP levels in the presence of functionally significant stenoses that may help better planning and identification of those patients with the functionally substantial atherosclerotic burden.

The predictive value of MAPH score for determining thrombus burden in patients with non-ST segment elevation myocardial infarction.

BACKGROUND: A high thrombus burden has been connected with poor clinical events in patients with non-ST segment elevation myocardial infarction (NSTEMI). In patients with STEMI, a high MAPH score has been associated with a large thrombus burden. However, the predictive value of the MAPH score in determining the thrombus burden in patients with NSTEMI is unclear. The present report aimed to evaluate the prognostic role of the MAPH score in the estimating coronary thrombus burden in NSTEMI patients. The study patients were split into two groups according to their thrombus grade. The low shear rate (LSR) and high shear rate (HSR) were estimated by haematocrit levels and serum total protein levels. The MAPH score was calculated by adding mean platelet volume (MPV) levels and age, in addition to total protein and haematocrit. RESULTS: The patients with a high thrombus burden (HTB) had a higher LSR, higher HSR and higher MAPH score compared to patients with low thrombus burden. MAPH score was found to be an independent predictors of HTB in Model 1 (OR: 1.124, 95% CI: 1.011-1.536; p = 0.039) and Model 2 (OR: 1.236; 95% CI: 1.002-1.525; p = 0.047). The cut-off value of the MAPH score for predicting HTB was 2 based on the Youden index. CONCLUSIONS: The MAPH score, which calculated by adding MPV levels and age, in addition to total protein and haematocrit, is a novel, easily accessible score. The MAPH score at both LSR and HSR was an independent predictor of HTB.

Documentation of impaired coronary blood flow in chronic obstructive pulmonary disease patients.

BACKGROUND: In the current study, the effects of moderate to severe chronic obstructive pulmonary disease (COPD) on coronary blood flow in patients with angiographically proven normal coronary arteries was evaluated. METHODS AND RESULTS: A total of 85 patients with moderate to severe COPD and 39 age- and sex-matched control partcipants, who underwent diagnostic coronary angiography and found to have normal epicardial coronary angiogram constituted the COPD and control groups, respectively. The 2 groups were compared for Thrombolysis In Myocardial Infarction (TIMI) frame counts in each major coronary artery. The TIMI frame count of the COPD group was significantly higher than that of control group for all 3 major individual coronary arteries: left anterior descending (corrected), 37+/-13 vs 20+/-4; right coronary artery, 32+/-14 vs 21+/-4; and left circumflex artery, 34+/-12 vs 20+/-5, (P<0.001 for all). In addition, TIMI frame counts in individual coronary arteries were found to be positively correlated with forced expiratory volume 1 s percent, serum high sensitive C-reactive protein and fibrinogen concentrations, in the COPD group. CONCLUSIONS: Our findings suggest that an increased slow coronary flow might be a manifestation of harmful effects of COPD on the coronary circulation, regardless of the underlying mechanism.

Decreased plasma concentrations of adiponectin in patients with slow coronary flow.

Adiponectin has multiple protective effects on vascular endothelium through anti-inflammatory and anti-atherogenic properties. Recent data suggested that endothelial activation and inflammation may contribute to the pathogenesis of slow coronary flow (SCF). Therefore, we investigated whether adiponectin plasma concentrations were decreased in patients with SCF compared to subjects with normal coronary flow. The study population consisted of 35 patients with angiographically documented SCF in all three coronary arteries and 35 sex- and age-matched cases with normal coronary flow. Coronary flow rates of all participants were determined by Thrombolysis in Myocardial Infarction (TIMI) frame count. Plasma adiponectin concentrations were measured by an enzyme-linked immunosorbent assay method using commercially available adiponectin kits. There were no statistically significant differences between the patients with SCF and the subjects with normal coronary flow in terms of demographic characteristics and cardiovascular risk factors (P>0.05). Plasma adiponectin concentrations of patients with SCF were found to be significantly lower than those with normal coronary flow (4.77+/-3.86 mg/ml vs 10.8+/-6.60 mg/ml, P=0.001, respectively). Plasma adiponectin levels were correlated significantly and inversely with mean TIMI frame count in patients with SCF (r= -0.441, P=0.008). Furthermore, the Receiver Operator Characteristics curve of adiponectin concentrations showed that an adiponectin <4.6 mg/ml is associated with SCF with a sensitivity of 68.6%, specificity of 82.9%, positive predictive value of 80.0%, and negative predictive value of 72.5%. Our findings suggest that endothelial inflammation may play a role in the pathogenesis of SCF phenomenon.

The use of three-dimensional echocardiography in the visualization of pseudoaneurysm of the mitral-aortic intervalvular fibrosa.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIF) is an uncommon but serious complication of aortic valve endocarditis. A 23-year-old woman was referred to our institution with the diagnosis of aortic valve endocarditis thought to be complicated by an aortic root abscess. Two-dimensional transthoracic echocardiography revealed a vegetation attached to the left coronary cuspis of the aortic valve and a false aneurysm-like structure in the MAIF at the left ventricular outflow tract. The diagnosis of MAIF pseudoaneurysm was confirmed by three-dimensional echocardiography. The patient died a few hours after admission because of worsening of her neurological status. An abscess-like structure detected in a patient with aortic valve endocarditis should be differentiated from a pseudoaneurysm of the MAIF.

Impact of plasma adiponectin levels to the presence and severity of coronary artery disease in patients with metabolic syndrome.

OBJECTIVES: Adiponectin is thought to serve a protective function for the coronary endothelium by inhibiting many of the crucial steps in atherosclerotic process. Previous research has indicated an increased risk of coronary artery disease (CAD) in patients with metabolic syndrome (MetS). The objective of this study was to investigate whether plasma adiponectin concentrations were associated with the presence and severity of CAD in patients with MetS undergoing coronary angiography. METHODS: We measured plasma adiponectin levels in 167 consecutive patients with MetS undergoing coronary angiography. The severity of coronary atherosclerosis was defined by using Gensini score system. RESULTS: CAD was found in 70.1% of the patients. Patients with significant CAD had lower plasma adiponectin concentrations than those without CAD (4.14+/-3.83 vs. 8.94+/-6.63 microg/ml, P<0.001). Multiple regression analysis demonstrated that plasma adiponectin level was independently associated with CAD (odds ratio: 0.86; 95% confidence interval: 0.78-0.94; P=0.001). Plasma adiponectin levels were inversely related to the Gensini score (rho: -0.480, P<0.001) and predicted the severity of coronary atherosclerosis independent of other risk factors (beta: -0.054; 95% confidence interval: -0.074--0.034; P<0.001). CONCLUSIONS: These findings suggest that hypoadiponectinemia may play a role in the development of coronary atherosclerosis and the observation of adiponectin levels may be indicative of the presence of significant CAD in patients with MetS.

Relation of admission QRS duration with development of angiographic no-reflow in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous interventions.

BACKGROUND: Although QRS-complex changes during ischemia have been described previously, their relation with no-reflow is not clear. PURPOSE: To evaluate relation of admission QRS duration with angiographic no-reflow, we studied 162 patients who underwent primary angioplasty. METHODS: Twelve-lead electrocardiogram with a paper speed of 50 mm/s was recorded on admission and repeated after angioplasty. Patients were divided into reflow and no-reflow groups based on postangioplasty coronary thrombolysis in myocardial infarction flow grade. RESULTS: Patients in the no-reflow group (26 patients) were older (P = .001) and had significantly longer pain-to-balloon interval (P = .007). The patients in the no-reflow group had significantly longer QRS duration on admission electrocardiogram compared with patients in the reflow group (interquartile range, 80-93 [median, 84] milliseconds vs 60-80 [median, 76] milliseconds, respectively; P < .001). After adjusting all variables, QRS duration on admission was found to be independently related to angiographic no-reflow (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P = .003). CONCLUSION: QRS duration on admission may be valuable in predicting no-reflow.

A hydatid cyst of the interventricular septum diagnosed incidentally by multislice computed tomography.

Cardiac involvement of the hydatid disease is uncommon. In this report a case of 54-year-old patient with a hydatid cyst in the interventricular septum was presented. The cyst was detected incidentally by cardiac multislice computed tomography and transthoracic echocardiographic appearances of the cyst raised the suspicion of cardiac echinococcosis. The patient was referred to surgery immediately for the removal of the cyst in order to prevent the potentially life threatening complications. The postoperative period was uneventful and she was discharged on albendazole therapy.

[Cardiac resynchronization therapy: Is the ECG criterion satisfying? What are the alternative modalities?]. / Kardiyak resenkronizasyon tedavisi: EKG ölçütü yeterli mi? Alternatif yöntemler nelerdir?

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality markedly in patients with heart failure and prolonged QRS duration. Although QRS duration seems to be the main inclusion criterion for CRT in major randomized studies, nonresponders account for nearly 30% to 40% of the patients. We reviewed information on and measurement of electrical and mechanical dyssynchrony, difficulties and weaknesses of electrocardiographic and echocardiographic indices of dyssynchrony, new and alternative diagnostic modalities, and controversial issues on predicting response to treatment. Although echocardiographic assessment together with new modalities seems to be reliable and applicable in clinical practice, appropriate patient selection remains challenging for large prospective randomized trials.