The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement.

INTRODUCTION: The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. METHODS: A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. RESULTS: Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. CONCLUSION: This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

The effect of body mass index on complications in cardiac implantable electronic device surgery.

BACKGROUND: Cardiac implantable electronic device (CIED) procedures are prone to complications. In our study, we investigated the effect of body mass index (BMI) on CIED-related complications. METHODS: 1676 patients who had undergone CIED surgery (de novo implantation, system upgrade, generator change, pocket revision or lead replacement) at two heart centers in Turkey and met the study criteria were included in our study. For analysis of primary and secondary endpoints, patients were classified as non-obese (BMI < 25 kg/m2 ), overweight (25 ≤ BMI < 30 kg/m2 ), and obese (BMI ≥ 30 kg/m2 ). The primary endpoint was accepted as cumulative events, including the composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to the device system. Secondary outcomes included each component of cumulative events. RESULTS: The rate of cumulative events, defined as primary outcome, was higher in the obese patient group, and we found a significant difference between the groups (3.0%, 4.3%, 8.9%, p = .001). CSH and pneumothorax rates were significantly higher in the obese patient group (0.3%, 0.9%, 1.9%, p = .04; 1.0%, 1.4%, 3.3%, p = .04, respectively). According to our multivariate model analysis; gender (OR:1.882, 95%CI:1.156-3.064, p = .01), hypertension (OR:4.768, 95%CI:2.470-9.204, p < .001), BMI (OR:1.069, 95%CI:1.012-1.129, p = .01) were independent predictors of cumulative events rates. CONCLUSIONS: Periprocedural complications associated with CIED (especially hematoma and pneumothorax) are more common in the group with high BMI.

The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement

ABSTRACT Introduction: The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. Methods: A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. Results: Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. Conclusion: This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

Unusual case report of malignant pheochromocytoma presenting with STEMI.

Background: Pheochromocytomas (PHEOs) are a group of tumours that leads to multiple symptoms and can induce hypercoagulability and promote thrombosis. Pheochromocytomas may also present without elevated serum and urinary markers. We aimed to provide tips and tricks for the diagnostic and therapeutic management of an unusual case of PHEOs. Case summary: Thirty-four-year-old woman with the unremarkable medical history presented with epigastric pain and dyspnoea. Electrocardiogram showed ST-segment elevation in the inferior limb leads. She underwent an emergency coronary angiogram, which showed a high thrombus burden in the distal right coronary artery. A subsequent echocardiogram demonstrated a 31 × 33 mm right atrial mass adhering to the inferior vena cava and abdominal computed tomography (CT) scan revealed a 113 × 85 mm necrotic mass in the left adrenal bed, with tumour thrombus extending proximally to the confluence of hepatic veins immediately inferior to the right atrium and distally to iliac vein bifurcation. Blood parameters, thrombophilia panel, vanillylmandelic acid, 5 hydroxy indole acetic acid, and homovanillic acid levels were normal. Tissue sampling confirmed the diagnosis of PHEOs. The surgical procedure was not planned due to the presence of metastatic foci on imaging, including positron emission tomography (PET)-CT. Anticoagulation with rivaroxaban and treatment with 177Lu-DOTATATE-based peptide receptor radionuclide therapy (PRRT) was initiated. Discussion: The coexistence of arterial and venous thrombosis is extremely rare in patients with PHEOs. Multidisciplinary approaches are required for the care of such patients. Catecholamines likely contributed to the development of thrombosis in our patient. Early recognition of PHEOs is the key point to ameliorate clinical outcomes.

Catastrophic embolism of a suddenly ruptured isolated cardiac cyst hydatid: An unusual case report.

Hydatid cysts can be located in any organ or tissue system. Cardiac hydatid cyst is a rare, but fatal pathology. A 21-year-old male Syrian refugee patient with no previous known medical conditions was admitted to the hospital for chest pain and shortness of breath. He had increasing leg pain for 12 hours. Hydatid cyst rupture was detected on echocardiography. The peripheral artery thrombus and hydatid cyst membrane were removed with the embolectomy. The patient had renal and cranial infarctions. He underwent fasciotomy due to compartment syndrome. In conclusion, delayed diagnosis and treatment of cardiac hydatid cysts may result in a poor prognosis associated with the risk of rupture and is responsible for the spread of infection throughout the body as a result of the rupture. Even if there is an early diagnosis, surgical treatment supported by medical treatment is recommended very early.

Evaluation of Frontal QRS-T Angle in Patients with Coronary Artery Ectasia

Abstract Background: Coronary artery ectasia (CAE) is defined by focal enlargement of the coronary artery exceeding 1.5 times the adjacent normal segment. CAE can often cause arrhythmias, heart failure, sudden death, and myocardial ischemia. Ischemia due to microvascular dysfunction may be responsible for the ventricular heterogeneity in CAE. Objectives: The aim of our study was to evaluate the frontal QRS-T angle in patients with CAE. Methods: Our study included 55 patients with CAE and 50 individuals in the control group. Demographic characteristics and electrocardiographic parameters were compared between the two groups. Categorical variables were compared using the chi-square test. Continuous variables were compared using unpaired Student's t-test. P values < 0.05 were considered statistically significant. The frontal QRS-T angle was calculated from 12-lead electrocardiograms (ECGs) using the automatic report from the electrocardiography machine. Results: The average age of patients with CAE was 63.2 ± 3.4 years, with 18 women among them. The control group had an average age of 61.1 ± 3.2 years, with 28 women included. There was no significant difference in demographic parameters between the two groups. Compared to the control group, patients with CAE had significantly wider frontal QRS-T angle (p < 0.001), as well as longer QTmax duration, p = 0.002; Tp-Te interval, p = 0.02; and QT dispersion (QTd), p = 0.04. Conclusion: The frontal QRS-T angle can be calculated easily and time-efficiently using surface electrocardiography. In this study, we showed for the first time that the frontal QRS-T angle was significantly increased in patients with CAE.

The effect of coronary slow flow on ventricular repolarization parameters.

INTRODUCTION: Ischemia due to microvascular dysfunction may be responsible for the heterogeneity of ventricular repolarization in coronary slow flow. To our knowledge, there is no study in which QT interval, Tp-Te interval, index of cardiac-electrophysiological balance (iCEB), and frontal QRS-T angle were evaluated together in patients with CSF. In this study, we examined for the first time the relationship between all these myocardial repolarization parameters and CSF. MATERIALS AND METHODS: The study group included 178 patients (99 female, mean age: 50.6 ± 8.6 years) with isolated CSF without stenotic lesions and with angiographically proven normal coronary arteries. The control group included 120 patients (71 female, mean age: 49.3 ± 9.4 years) with normal coronary angiography. QRS duration, QT interval, QTc interval, Tp-Te interval, Tp-Te/QT, Tp- Te/QTc, iCEB score, and frontal QRS-T angle were calculated from 12­lead ECGs. RESULTS: There was no significant difference in demographic parameters between the two groups. Compared with the control group, patients with CSF had significantly longer QTmax duration, QT dispersion, Tp-Te interval, and higher iCEB score, wider frontal QRS-T angle. CONCLUSION: In our study, we found that many of the ventricular repolarization parameters were adversely affected in patients with CSF. Impaired parameters may be associated with the risk of malignant ventricular arrhythmias.

Prognostic value of age, creatinine, and left ventricular ejection fraction risk score in patients evaluated with fractional flow reserve: a cross-sectional study

SUMMARY OBJECTIVE: In this study, we investigated the relationship between age, creatinine, and left ventricular ejection fraction risk score and the severity of coronary lesions detected by applying fractional flow reserve in the patient group presenting with chronic coronary syndrome. Also, we presented long-term follow-up results in patients whose age, creatinine, and left ventricular ejection fraction score was evaluated by the fractional flow reserve procedure. METHODS: This study was planned retrospectively and in two centers. For this purpose, 114 patients who met the study criteria and who underwent elective fractional flow reserve between January 2014 and January 2019 were included in the study. Age, creatinine, and left ventricular ejection fraction was calculated as age/left ventricular ejection fraction +1 (if estimated glomerular filtration rate<30 mL/min). RESULTS: They were divided into two groups according to the cutoff value of the age, creatinine, and left ventricular ejection fraction score. A total of 76 patients had an age, creatinine, and left ventricular ejection fraction score of ≤1.17 (Group I) and 38 patients had an age, creatinine, and left ventricular ejection fraction score of >1.17 (Group II). The number of patients with severe lesions in fractional flow reserve was significantly higher in Group II compared with Group I (60.5 vs. 32.9%, p=0.005). According to the Kaplan-Meier analysis, a significant increase was observed in major adverse cardiac events and mortality during the follow-up period in the group with a high-risk score (Log Rank: 15.01, p<0.001 and Log Rank: 8.51, p=0.004, respectively). CONCLUSION: In light of the data we obtained from our study, we found a correlation between the severity of the lesion detected in fractional flow reserve and the age, creatinine, and left ventricular ejection fraction scores. In addition, we found that patients with high age, creatinine, and left ventricular ejection fraction scores had higher mortality and major adverse cardiac events rates during follow-up.

Comparison of pain levels of traditional radial, distal radial, and transfemoral coronary catheterization

SUMMARY OBJECTIVE: The aim of our study was to compare the traditional radial artery, distal radial artery, and transfemoral artery, which are vascular access sites for coronary angiography, in terms of pain level using the visual analog scale. METHODS: Between April 2021 and May 2022, consecutive patients from three centers were included in our study. A total of 540 patients, 180 from each of the traditional radial artery, distal radial artery , and transfemoral artery groups, were included. The visual analog scale was applied to the patients as soon as they were taken to bed. RESULTS: When the visual analog scale was compared between the groups, it was found to be significantly different (transfemoral artery: 2.7±1.6, traditional radial artery: 3.9±1.9, and distal radial artery: 4.9±2.1, respectively, p<0.001). When the patients were classified as mild, moderate, and severe based on the visual analog scale score, a significant difference was found between the groups in terms of body mass index, process time, access time, and number of punctures (p<0.001). Based on the receiver operating characteristic analysis, body mass index>29.8 kg/m2 predicted severe pain with 72.5% sensitivity and 73.2% specificity [(area under the curve: 0.770, 95%CI: 0.724-0.815, p<0.0001)]. CONCLUSION: In our study, we found that the femoral approach caused less access site pain and a high body mass index predicts severe pain.

Evaluation of the Cardiac Conduction System in Fibromyalgia Patients With Complaints of Palpitations.

Objective This study aimed to investigate the influence of fibromyalgia syndrome (FMS) on the cardiac conduction system and assess patients' palpitation complaints using 24-h ambulatory ECG (Holter {Maynard, MA: Northeast Monitoring, Inc.}) monitoring. Methods Ninety patients with FMS and 70 healthy controls were included in this research. ECG was performed on all participants, and ECG parameters were calculated. Holter monitoring was conducted, and the recordings were analyzed. The results of time-domain heart rate variability (HRV) were evaluated. Results The patient group's mean age was 38.3±6.3 years. There were no statistically significant differences in demographic or laboratory parameters across the groups (p>0.05). The findings of a 24-h Holter ECG recording did not vary significantly between the groups (p=0.182). In the study group, the values for the standard deviation of R-R intervals (SDNN), low frequency (LF), and low/high frequency (LF/HF), which are known as HRV indicators, were substantially different between the two groups (p<0.05). Conclusions The study indicated that the risk of arrhythmias did not increase even though FM patients complained of palpitations.

The effect of nutritional scores on mortality in COVID-19 patients

SUMMARY OBJECTIVES: While studies on the treatment for the coronavirus disease 2019 (COVID-19) pandemic continue all over the world, factors that increase the risk of severe disease have also been the subject of research. Malnutrition has been considered an independent risk factor. Therefore, we aimed to investigate the clinical effect of dietary habits and evaluate the prognostic value of the Controlling Nutritional Status score in the COVID-19 patients we followed up. METHODS: A total of 2760 patients hospitalized for COVID-19 were examined. Patients were retrospectively screened from three different centers between September 1 and November 30, 2020. A total of 1488 (53.9%) patients who met the criteria were included in the study. Risk classifications were made according to the calculation methods of prognostic nutritional index and Controlling Nutritional Status scores and total scores. The primary outcome of the study was in-hospital mortality. RESULTS: The groups with severe Controlling Nutritional Status and prognostic nutritional index scores had a significantly higher mortality rate than those with mild scores. In the multivariable regression analysis performed to determine in-hospital mortality, the parameters, such as age (OR 1.04; 95%CI 1.02-1.06, p<0.001), admission oxygen saturation value (SaO2) (OR 0.85; 95%CI 0.83-0.87, p<0.001), and Controlling Nutritional Status score (OR 1.34; 95%CI 1.23-1.45, p<0.001), were independent predictors. The patient groups with a low Controlling Nutritional Status score had a higher rate of discharge with recovery (p<0.001). CONCLUSIONS: Higher Controlling Nutritional Status scores may be effective in determining in-hospital mortality in patients with COVID-19. Nutrition scores can be used as a useful and effective parameter to determine prognosis in patients with COVID-19.

Relationship between contrast-induced nephropathy and long-term mortality after percutaneous coronary intervention in patients with chronic coronary total occlusion

SUMMARY OBJECTIVE: Intervention in chronic total occlusion lesions involves long procedure time, a serious contrast load, and complex procedures. In this study, we aimed to investigate mortality rate of patients who had procedural coronary angiography done for chronic total occlusion lesions in coronary angiography series and who developed contrast-induced nephropathy. METHODS: A total of 218 patients with chronic total occlusion lesion in at least one coronary artery, from three different medical centers, who underwent procedural coronary angiography were recruited for the study. Patient population was divided into two groups: those who developed contrast-induced nephropathy and those who did not. Mortality due to all causes was investigated between both groups throughout a 100-month follow-up. RESULTS: Mean age of patients with incidence of contrast-induced nephropathy was 66.7±11.8, and 23.8% of them were comprised by female. We found a significantly higher mortality in long-term follow-up in the patient group with contrast-induced nephropathy (42.9 vs. 57.1%, p≤0.001). According to Kaplan-Meier analysis performed additionally, survival during follow-up was significantly shorter in this group and, in logistic regression analysis, it was an independent predictor of mortality (OR 3.02; 95%CI 1.41-6.45, p=0.004). CONCLUSION: We identified that the development of contrast-induced nephropathy is associated with long-term mortality. It might be possible to reduce adverse events with prophylactic approaches before the procedure and close follow-up of such patients after the procedure.

A comparison of postoperative complications following cardiac implantable electronic device procedures in patients treated with antithrombotic drugs.

BACKGROUND: The incidence of postoperative complications following cardiac implantable electronic device (CIED) procedures in patients treated with antithrombotic drugs has not been studied sufficiently. Here we present a comparison of complications after CIED implantations. METHODS: Using an observational study design, the study included 1807 patients with a taking antiplatelet drugs (n: 1601), nonvitamin K anticoagulants (NOAC) (n: 136), and warfarin (n: 70) undergoing CIED surgery. Primary endpoint was accepted as cumulative events including composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to device system. Secondary outcomes included each compenent of cumulative events. Multivariable analysis was performed to identify predictors of cumulative events. RESULTS: The overall cumulative event rate was 3.7% (67 of 1807). Cumulative events occured 3.1% (50 of 1601) in the antiplatelet, 5.1% (7 of 136) NOAC, and 14.3% (10 of 70) warfarin groups (p < 0.001). CSH occurred in 2 of 70 patients (2.9%) in the warfarin group, as compared with 5 of 1601 (0.3%) in the antiplatelet group (p: 0.032). However, no significant differences were found between NOAC and warfarin groups in terms of CSH (0.7% vs. 2.9% respectively, p: 0.267). Warfarin treatment was an independent predictor of cumulative events and increased 2.9-fold the risk of cumulative events. Major surgical complications were rare and did not differ significantly between the study groups. CONCLUSIONS: The incidence and severity of complications may be lower in patients treated with periprocedurally antiplatelet or NOAC therapy when compared with warfarin therapy. Further randomized control studies are required to confirm our findings.

Renal acoustic radiation force impulse elastography in the evaluation of coronary artery disease.

Background Renal insufficiency may occur in patients with coronary artery disease (CAD). Acoustic radiation force impulse (ARFI) is a method for quantifying tissue elasticity, which could be used as an additional diagnostic test for renal insufficiency and provide an additional contribution to the determination of CAD. Purpose To evaluate ARFI elastography with shear wave velocity (SWV) measurements in the diagnosis of mild-to-moderate chronic kidney disease (CKD) in CAD patients, and to analyze the relationship between the severity of CAD assessed by the Gensini scoring system and kidney stiffness. Material and Methods The study included 76 CAD patients and 79 healthy volunteers. SWV was measured for each kidney in the both groups. The CAD group was divided into two subgroups based on Gensini score: mild CAD and severe CAD. SWV values of the CAD patients were compared to those of the healthy volunteers; values of subgroups were also compared with each other. Results The patient group had significantly lower renal mean SWV values than those of the healthy group (1.87 ± 0.58 vs. 2.34 ± 0.38, P < 0.01). The SWV value decreased as the eGFR level decreased. Mean SWV values for kidneys of the patients with severe CAD were lower than those of the mild CAD patients (1.64 ± 0.39 vs. 2.42 ± 0.60, P < 0.01). Conclusion renal mean SWV values of CAD patients decreased in proportion to the reduction in eGFR, and the SWV values decreased as the severity of CAD increased. ARFI elastography is a novel technique for diagnosing CKD and defining illness severity in CAD patients.

Assessment of the neutrophil/lymphocyte ratio in patients with supraventricular tachycardia.

OBJECTIVE: The neutrophil/lymphocyte ratio (NLR) has been evaluated as a new predictor of cardiovascular risk. Inflammation has been shown to be associated with various arrhythmias including supraventricular tachycardias (SVTs). In this study, we aimed to investigate the relation between NLR and SVT in patients with a documented atrial tachyarrhythmia. METHODS: The study used a retrospective cross-sectional design. Patients who had SVT but were otherwise healthy were included. The exclusion criteria included drug use (except antiarrhythmic agents), morbid obesity, acute or chronic infection, inflammatory diseases, systemic diseases, and cancer. Total and differential leukocyte counts and routine biochemical tests were performed before the ablation procedure. RESULTS: The study included 150 patients with SVT and 98 healthy controls. The biochemical and hematological parameters were comparable between the groups, except neutrophil and lymphocyte counts. The neutrophil count was significantly higher (4.7±1.5x103/µL versus 4.1±1.0x103/µL; p<0.001) and lymphocyte count was significantly lower (2.2±0.6x103/µL versus 2.5±0.6x103/µL; p=0.001) in the SVT group than in the control group. As a result, the SVT group had significantly higher NLR values than the control group (2.2±0.9 versus 1.7±0.5; p<0.001). In addition, NLR values were higher in patients in whom tachycardia was induced during an electrophysiological study (EPS) (2.3±0.9 versus 2.0±0.8; p=0.02). The association between NLR and SVT remained significant after multivariate analysis (odds ratio: 1.5, 95% confidence interval: 1.001-2.263, p=0.049). CONCLUSION: Our study indicated that NLR values were significantly higher in patients with documented SVT than in control subjects. Inducibility of SVT during EPS was associated with higher NLR values.