David's procedure for pulmonary artery aneurysm.

Pulmonary artery aneurysm (PAA) is a rare entity with fatal complications. Its silent course contributes to large aneurysms with compression symptoms. We present a 39-year-old female idiopathic pulmonary arterial hypertension patient with a giant PAA causing severe pulmonary regurgitation (PR) and symptomatic left main coronary artery compression (LMCA). Since she had a failed LMCA stenting attempt, she underwent surgery. A valve-sparing David-like pulmonary trunk reconstruction and coronary artery bypass were performed. This case illustrates that David-like reconstruction procedure can be applied to the PAA with severe PR.

A rare complication of transcatheter aortic valve replacement: Free-floating nose cone.

Presently described is a case in which the tip of the delivery catheter system (nose cone) has been broken during catheter removal after valve deployment in a femoral transcatheter aortic valve replacement procedure and the successful management of this rare complication.

Missed unroofed coronary sinus.

Coronary sinus atrial septal defect (ASD) is a rare congenital cardiac anomaly, which might be difficult to diagnose. In this report, we describe a patient with small secundum ASDs and an associated large coronary sinus ASD, which had been missed at initial evaluation. The diagnosis of coronary sinus ASD was established by using transesophageal echocardiography after percutaneous closure of a small secundum ASD at another center. Patient underwent corrective surgery.

Relationship of admission neutrophil-to-lymphocyte ratio with in-hospital mortality in patients with acute type I aortic dissection.

AIM: Acute aortic dissection is a life-threatening cardiovascular emergency. Neutrophil-to-lymphocyte ratio is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. The aim of the present study was to evaluate the relationship between admission neutrophil-to-lymphocyte ratio and in-hospital mortality in acute type I aortic dissection. MATERIALS AND METHODS: We retrospectively evaluated 123 consecutive patients who had undergone emergent surgery for acute type I aortic dissection. Patients were divided into 2 groups as patients dying in the hospital (Group 1) and those discharged alive (Group 2). All parameters, including neutrophil-to-lymphocyte ratio, were compared between the 2 groups and predictors of mortality was estimated by using multivariate analysis. RESULTS: A total of 104 patients (79 males, mean age: 55.2 + 14 years) were included in the final analysis. In multivariate analyses, cross- clamp time, cardiopulmonary bypass time, intensive care-unit duration, platelet count, and neutrophil-to-lymphocyte ratio were found to be independent predictors of mortality. Patients with higher neutrophil-to-lymphocyte ratios had a significantly higher mortality rate (hazard ratio: 1.05; 95% CI: 1.01-1.10; P = 0.033). Receiver operating characteristic analysis revealed that using a cut-off point of 8, neutrophil-to-lymphocyte ratio predicts mortality with a sensitivity of 70% and specificity of 53%. CONCLUSION: This study suggests that admission neutrophil-to-lymphocyte ratio is a potential predictive parameter for determining the in-hospital mortality of acute type I aortic dissection.

Papillary muscle repositioning as a subvalvular apparatus preservation technique in mitral stenosis patients with normal left ventricular systolic function.

Subvalvular apparatus preservation is an important concept in mitral valve replacement (MVR) surgery that is performed to remedy mitral regurgitation. In this study, we sought to determine the effects of papillary muscle repositioning (PMR) on clinical outcomes and echocardiographic left ventricular function in rheumatic mitral stenosis patients who had normal left ventricular systolic function. We prospectively assigned 115 patients who were scheduled for MVR surgery with mechanical prosthesis to either PMR or MVR-only groups. Functional class and echocardiographic variables were evaluated at baseline and at early and late postoperative follow-up examinations. All values were compared between the 2 groups. The PMR group consisted of 48 patients and the MVR-only group of 67 patients. The 2 groups' baseline characteristics and surgery-related factors (including perioperative mortality) were similar. During the 18-month follow-up, all echocardiographic variables showed a consistent improvement in the PMR group; the mean left ventricular ejection fraction deteriorated significantly in the MVR-only group. Comparison during follow-up of the magnitude of longitudinal changes revealed that decreases in left ventricular end-diastolic and end-systolic diameters and in left ventricular sphericity indices, and increases in left ventricular ejection fractions, were significantly higher in the PMR group than in the MVR-only group. This study suggests that, in patients with rheumatic mitral stenosis and preserved left ventricular systolic function, the addition of papillary muscle repositioning to valve replacement with a mechanical prosthesis improves left ventricular dimensions, ejection fraction, and sphericity index at the 18-month follow-up with no substantial undesirable effect on the surgery-related factors.

Evaluation of positive inotropic drug effects on thyroid hormone levels after open heart surgery.

OBJECTIVE: The aim of this study was to examine the effects of positive inotropic drugs, including adrenaline, dopamine, and dobutamine on thyroid hormone levels following open heart surgery. METHODS: We analyzed free thyroid hormones (FT3 and FT4) and thyroid-stimulating hormones (TSH) in 200 consecutive patients undergoing open heart surgery. Patients were divided into 5 groups according to the inotropic drug administration as follows: Group A (n = 46) received dopamine alone; Group B (n = 40), dopamine and dobutamine; Group C (n = 36), dopamine, dobutamine, and adrenaline; Group D (n = 32), adrenaline alone; and Group E (n = 46), placebo. Procedural factors affecting thyroid hormones were recorded and included cardiopulmonary bypass (CPB) time, cross-clamping time, degree of hypothermia, and the duration and doses of positive inotropic drugs. Blood samples for hormone assays were collected before initiation of inotropic drug therapy (baseline) and postoperatively at 24, 72, and 120 hours after drug therapy. RESULTS: FT3, FT4, and TSH levels at baseline were similar in all groups. Although there was a trend showing very slight increases in thyroid hormone levels from baseline to the 24th, 72nd, and 120th postoperative hours after drug therapy, these changes were not significant, and there were also no significant differences between the groups. There was also no significant statistical difference in CPB time, cross-clamping time, degree of hypothermia, and duration and doses of positive inotropic drugs between groups. CONCLUSION: Although thyroid hormone levels were affected by positive inotropic drug usage after open heart surgery, this effect was not significant and thyroid hormone levels remained within normal ranges.

Impaired coronary flow reserve evaluated by echocardiography is associated with increased aortic stiffness in patients with metabolic syndrome: an observational study.

OBJECTIVE: Metabolic syndrome (MetS) is a strong predictor of cardiovascular events and coronary flow reserve (CFR), an indicator of microvascular function, has been found to be impaired in MetS. Aortic stiffness (AS) is a simple and effective method for assessing arterial elasticity. The aim of this study was to evaluate whether there is an independent association of impaired coronary flow and aortic elasticity in patients with MetS. METHODS: Forty-six patients (mean age 47.3 ± 6.6 years) with the diagnosis of MetS according to the ATP III update criteria and 44 age and gender matched controls (mean age 46.0 ± 6.1 years) were included into the cross-sectional observational study. Peak diastolic coronary flow velocities were measured in left anterior descending artery by pulsed wave Doppler at baseline and after adenosine infusion, and CFR was calculated as the ratio of hyperemic to baseline velocities. Aortic strain, distensibility and stiffness were calculated by M-mode echocardiography. Statistical analysis was performed by using Student t-test, Chi-square test, Pearson correlation and linear regression analyses. RESULTS: CFR was significantly lower in patients with MetS than in controls (2.3 ± 0.2 vs 2.7 ± 0.2, p<0.001). In the MetS group, aortic distensibility (10.4 ± 3.5 cm².dyn⁻¹.10⁻6 vs. 12.7 ± 3.4 cm2.dyn⁻¹.10⁻6, p=0.002) was decreased and AS was significantly increased (6.5 ± 2.0 vs. 3.2 ± 0.8, p<0.001). In multivariate linear regression analysis, AS (ß=-0.217, p=0.047), systolic blood pressure (ß=-0.215, p=0.050) and waist circumference (ß=-0.272, p=0.012) had an independent relationship with impaired CFR. CONCLUSION: This study demonstrated that coronary flow reserve is impaired in patients with MetS and there is an independent relationship between impaired CFR and increased aortic stiffness, systolic blood pressure or waist circumference.

Impaired coronary flow reserve is associated with increased echocardiographic epicardial fat thickness in metabolic syndrome patients.

OBJECTIVES: Metabolic syndrome (MetS) is a strong predictor of cardiovascular events and coronary flow reserve (CFR), an indicator of microvascular function, has been found to be impaired in MetS. Epicardial fat thickness (EFT) reflects visceral adiposity and is considered an important cardiometabolic marker. In this study, we aimed to examine the presence of an association between CFR and EFT in MetS patients. METHODS: Forty-six MetS patients (25 men, mean age 47.3±6.6 years) and 44 age-matched and sex-matched controls (24 men, mean age 46.0±6.1 years) were prospectively studied. Both CFR and EFT were measured by transthoracic echocardiography. Peak diastolic coronary flow velocities were measured in the left anterior descending artery by pulsed wave Doppler at the baseline and after adenosine infusion, and CFR was calculated as the ratio of hyperemic to baseline velocities. RESULTS: The waist circumference, total and low-density lipoprotein-cholesterol, fasting glucose, triglycerides, systolic and diastolic blood pressures, and high sensitive C-reactive protein were significantly higher in MetS patients. The mean EFT was significantly higher in MetS patients compared with the controls (8.7±0.2 vs. 4.8±0.1 mm, P<0.001); however, CFR was significantly lower in MetS patients (2.3±0.2 vs. 2.7±0.2, P<0.001). CFR was correlated significantly with BMI, waist circumference, high-density lipoprotein-cholesterol, triglycerides, fasting glucose, high sensitive C-reactive protein, and EFT. In regression analysis, MetS itself and EFT were found to be independent predictors of impaired CFR. CONCLUSION: CFR is impaired in MetS patients. MetS itself and increased EFT are associated independently with coronary microvascular dysfunction and EFT is a predictor of worse CFR even after accounting for the presence or absence of the MetS.

Extremely rare cardiac involvement: recurrent pericardial hydatid cyst.

Echinococcus granulosus is a common infestation in sheep and cattle raising countries. Although it is typically encountered in liver and lung, rare cardiac involvement of this infestation has very important clinical complications such as heart failure, valve regurgitation, pericardial effusion-tamponade and arrhythmia. In addition, pericardial infestation is an extremely rare condition of Echinococcus granulosus. Here, we report a case of recurrent pericardial hydatid cyst presenting exertional dyspnea, palpitation and presyncope attacks in a 72-year-old man. The diagnosis of recurrent pericardial hydatid cyst was made by transthoracic echocardiography, computed tomography and surgical history.

Bronchogenic cyst of interatrial septum.

Bronchogenic cyst, also known as inclusion cyst, is a type of congenital endodermal heterotropia derived from an abnormal development of the ventral diverticulum of the foregut or the tracheobronchial tree during embryogenesis. Its interatrial localization is extremely rare and making a final diagnosis without surgery challenges the clinician. Herein, we report a 58-year-old male patient who had an interatrial bronchogenic cyst related to transient ischemic attack.

Rare postsurgical complication of atrial septal defect closure: right inflow obstruction due to inadvertent suturing of eustachian valve to interatrial septum.

We report the case of a 20-year-old woman who received corrective surgery for a secundum atrial septal defect, during which right atrial inflow obstruction developed because of inadvertent suturing of the eustachian valve to the interatrial septum. Although reliable cardiac surgical techniques are available, this rather rare complication may have deleterious results for patients. If a previously absent murmur is detected in the lower left parasternal border after atrial septal defect surgery, right atrial inflow obstruction caused by the eustachian valve should be kept in mind and further careful examination undertaken.

Thrombus-in-transit entrapped in a patent foramen ovale: a complication of brucellosis.

Brucella infection may cause vascular complications such as deep venous thromboembolism. This is the first report on an entrapped thrombus in a patent foramen ovale (PFO) in a patient with Brucella infection. A 43-year-old woman was admitted with complaints of fever, dyspnea, malaise, myalgia, and pretibial edema. Clinical and laboratory findings were consistent with brucellosis. Transthoracic echocardiography demonstrated a mobile, hyperechoic worm-like thrombus entrapped in a PFO. Right ventricular enlargement and elevated systolic pulmonary artery pressure (77 mmHg) showed acute pulmonary embolism. Multidetector computed tomography revealed a huge thrombus, 11.7 cm in length, in the bifurcation of the main pulmonary artery. Considering the huge size of the right heart thrombus and hemodynamically significant acute pulmonary embolism, open heart surgery was performed, during which an 11-cm thrombus was found extending from the right atrium across the PFO into the left atrium. The interatrial septum was excised en bloc together with the thrombotic mass and the PFO was closed. Pulmonary thromboendarterectomy was also performed. After surgery, systolic pulmonary artery pressure decreased to 38 mmHg and the patient was discharged without complications.

Primary cardiac undifferentiated sarcoma: role of intraoperative imprint cytology and frozen section of two cases.

Primary cardiac tumors are very rare, and a vast majority of such malignant tumors are sarcomas. Associated symptoms are usually vague and nonspecific resulting in a late diagnosis and poorer prognosis. Most cardiac sarcomas have been reported in autopsy series. Although echocardiography may help make a diagnosis of a cardiac sarcoma, histopathological confirmation is quintessential. Presented here are two cases of patients who underwent successful surgery for the removal of a cardiac tumor, along with echocardiographic, cytological, and histopathological findings as well as a compact literature review. In both patients, the masses were on the surface of the mitral valve, and intraoperative evaluation of frozen sections and imprint cytology were indicative of a "probably malignant" mesenchymal tumor prompting more extensive surgical resection. Immunohistochemical staining of the resected material in both cases was only positive for vimentin, leading to a diagnosis of undifferentiated sarcoma. One of the patients died 3 months after surgery, while the other who received adjuvant chemotherapy was still alive after 4 months. Surgery remains the most definite treatment for cardiac sarcomas. The use of intraoperative frozen section and imprint cytology plays an important role in the decision to extend surgical resection.

Association of serum fetuin-A with valvular calcium concentration in rheumatic mitral valve disease.

BACKGROUND AND AIM OF THE STUDY: Fetuin-A is an acute-phase glycoprotein that inhibits ectopic calcification. The study aim was to assess serum fetuin-A levels in patients with rheumatic mitral valve disease (RMVD), and to evaluate the association of fetuin-A with the extent of mitral valve calcification, determined either echocardiographically or by the measurement of calcium and phosphorus concentrations in the resected valve tissues. METHODS: The study group comprised 21 patients (14 females, seven males; mean age 48 +/- 12.4 years) with RMVD, who were scheduled for mitral valve replacement surgery, while 30 age- and gender-matched healthy subjects (17 females, 13 males; mean age 43.6 +/- 11.1 years) served as a control group. Baseline serum fetuin-A levels were measured using ELISA, and high-sensitivity C-reactive protein (hs-CRP) levels using immunonepholometry. A Wilkins score was calculated using transesophageal echocardiography, and the resected valve tissues were analyzed for concentrations of calcium and phosphorus. RESULTS: Serum fetuin-A levels were lower and hs-CRP levels higher in the study group than in controls (300.4 +/- 92.5 microg/ml versus 352.6 +/- 55.3 microg/ml, p = 0.028; and 1.9 +/- 1.2 mg/dl versus 0.3 +/- 0.2 mg/dl, p < 0.0001, respectively). An inverse correlation was found between serum fetuin-A and hs-CRP levels (r = -0.690, p = 0.001). A significant association of either serum fetuin-A or hs-CRP was also found to occur with calcium concentration in the mitral valve tissue (r = -0.684, p = 0.001, and r = 0.510, p = 0.018, respectively), but not with the Wilkins calcium score. Serum fetuin-A and phosphorus concentrations in the MV tissue were independent predictors of calcium concentration in the MV tissue. CONCLUSION: Serum fetuin-A, which is significantly decreased in patients with RMVD, is an independent predictor of calcium concentration in the mitral valve tissue.

Plasma levels of tumor necrosis factor-alpha and its receptors in patients with mitral stenosis and sinus rhythm undergoing percutaneous balloon valvuloplasty.

This study aimed to determine whether plasma levels of tumor necrosis factor-alpha (TNF-alpha) and soluble TNF receptor (sTNF-R) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm and to examine the effect of percutaneous mitral balloon valvuloplasty (PMBV) on these parameters. Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 +/- 8 years), who were scheduled for PMBV, and a well-matched control group consisting of 21 healthy volunteers (15 female, mean age 35 +/- 6 years) were enrolled in the study. Tumor necrosis factor-alpha and sTNF-R levels were compared between study patients and controls, and between peripheral and left atrium (LA) blood. Changes in TNF alpha and sTNF-R levels 24 h and 4 weeks after PMBV were analyzed. Significantly higher baseline TNF-alpha and sTNF-R levels were noted in the study group. In the study group, TNF-alpha and its receptors were also found to be higher in LA blood than in baseline peripheral blood. After PMBV, mitral valve area (MVA) increased and transmitral pressure gradient decreased significantly. At the 24th hour after PMBV, the TNF-alpha level decreased from 29.61 +/- 12.22 pg/ml to 22.42 +/- 8.81 pg/ml (P < 0.0001) and at the 4th week, from 22.42 +/- 8.81 pg/ml to 18.92 +/- 7.37 pg/ml (P < 0.0001). Similar reductions were observed in the sTNF-R level. Regression analysis between the difference in sTNF-R level measured 24 h after and before PMBV and the difference in MVA measured 24 h after and before PMBV showed a significant direct relationship between these variables. This study suggests that isolated rheumatic MS without atrial fibrillation is accompanied by increased TNF-alpha and sTNF-R level. The successful PMBV establishes a significant reduction in TNF-alpha and its receptors, probably due to improved postprocedural hemodynamic parameters.

Upper-extremity deep vein thrombosis and downhill esophageal varices caused by long-term pacemaker implantation.

Upper-extremity deep vein thrombosis is common after pacemaker or cardioverter-defibrillator implantation. Only 1% to 3% of patients with upper-extremity deep vein thrombosis become symptomatic. Downhill esophageal varices develop in the upper third of the esophagus as a result of the obstruction of the superior vena cava. Herein, we report the case of a 54-year-old man--a recipient of multiple implanted cardiac pacemakers--who presented with bilateral upper-extremity deep vein thrombosis. This severely symptomatic condition was complicated by very rare and life-threatening downhill varices of the upper esophagus, but without bleeding. To the best of our knowledge, this is the 1st report of this array of conditions.