The first reported case of embolic protection device implantation in a patient with prosthetic valve thrombosis treated with thrombolytic therapy: a case report.

Background: Prosthetic valve thrombosis (PVT) is a rare but one of the most dreaded complications of implanted mechanical valves. Although surgery is the first-line treatment modality particularly in symptomatic obstructive mechanical valve thrombosis, it is associated with high rates of morbidity and mortality. Thrombolytic therapy has also been used as an alternative to surgical treatment. The risk for cerebral thromboembolism associated with thrombolytic therapy seems to be the main limitation for its use in left-sided mechanical valve thrombosis. To the best of our knowledge, this is the first case of implantation of embolic protection devices during thrombolytic therapy of PVT. Case summary: Our report describes management of patient with obstructive PVT of the aortic valve. Fluoroscopy showed an immobile anterior disc of the aortic prosthesis. Transoesophageal echocardiography (TOE) detected the severely restricted prosthetic valve motions and a huge mass at the supravalvular site. A patient had very high surgical risks. Although, thrombolytic treatment was not without risk due to the large thrombus (>10 mm) increasing the risk of thromboembolism. We implanted embolic protection devices into both internal carotid arteries followed by the administration of a thrombolytic therapy with 50 mg Alteplase. After the procedure an embolized thrombus was detected at the apex at the left-sided placed device. There were no signs of transient ischaemic attack nor stroke, and the procedure was ended uneventful. The TOE performed on the next day confirmed successful resolution of the thrombus. Discussion: Mechanical left-sided prosthetic valve obstruction is a serious complication with high mortality and morbidity and requires urgent therapy. The choice between surgery, thrombolysis, and escalation of anticoagulation is considered on an individual basis. In patients with high surgical risk and high risk of embolization, an embolic protection device may be used in conjunction with thrombolytic therapy to decrease the risk of embolic cerebral events.

Red cell distribution width is increased in patients with ascending aortic dilatation.

OBJECTIVES: The prognostic importance of red cell distribution width (RDW) and neutrophil/lymphocyte ratio (NLR) in cardiovascular diseases has been shown. Ascending aortic dilatation (AAD) is a common cardiovascular disease and is associated with aortic wall inflammation and cystic degeneration. In this study, we aimed to investigate the relationship between serum levels of RDW, NLR and the presence of AAD. STUDY DESIGN: Two-hundred consecutive patients with AAD diagnosed by transthoracic echocardiography were prospectively recruited and were compared to 170 age-gender- matched subjects with normal aortic diameters. Complete blood counts (CBCs) were analyzed for hemoglobin, RDW and NLR counts, as well as mean corpuscular volume (MCV). If possible, results of CBC tests within the previous two years were also included and the averages were used. RESULTS: RDW [median 13.9, interquartile range (IQR) 1.40 vs. median 13.3, IQR 1.05%, p=0.01], NLR (median 2.04, IQR 1.09 vs. median 1.78, IQR 0.90, p=0.01) and high-sensitive C-reactive protein (hs-CRP) (median 0.60, IQR 0.80 vs. median 0.44, IQR 0.68 mg/L, p=0.01) levels were significantly higher in the AAD group compared to the control group. In univariate correlation analysis, ascending aortic diameters were correlated with RDW levels (r=0.31, p=0.01), NLR levels (r=0.15, p=0.01) and hs-CRP levels (r=0.12, p=0.03). In multivariate logistic regression analysis, increased levels of RDW and hs-CRP remained as the independent correlates of AAD in the study population. Receiver operating characteristic (ROC) curve analysis revealed that a RDW measurement higher than >13.8% predicted AAD with a sensitivity of 49.5% and a specificity of 82.8% (area under the curve [AUC] 0.681, p=0.01). CONCLUSION: In patients with AAD, RDW and hs-CRP levels are increased, which may indicate the role of inflammation in the pathogenesis of AAD.

Increased level of resistin predicts development of atrial fibrillation.

BACKGROUND: Resistin is a peptide hormone that is secreted from lipid cells and is linked to type-2 diabetes, obesity, and inflammation. Being an important adipocytokine, resistin was proven to play an important role in cardiovascular disease. We compared resistin levels in patients with and without atrial fibrillation (AF) to demonstrate the relationship between plasma resistin levels and AF. METHOD: One hundred patients with AF and 58 control patients who were matched in terms of age, gender, and risk factors were included in the trial. Their clinical risk factors, biometric measurements, echocardiographic work up, biochemical parameters including resistin and high-sensitivity C-reactive protein (hs-CRP) levels were compared. RESULTS: In patients with AF, plasma resistin levels (7.34±1.63ng/mL vs 6.67±1.14ng/mL; p=0.003) and hs-CRP levels (3.01±1.54mg/L vs 2.16±1.28mg/L; p=0.001) were higher than control group. In subgroup analysis, resistin levels were significantly higher in patients with paroxysmal (7.59±1.57ng/mL; p=0.032) and persistent AF (7.73±1.60ng/mL; p=0.006), but not in patients with permanent AF subgroups (6.86±1.61ng/mL; p=0.92) compared to controls. However, hs-CRP levels were significantly higher only in permanent AF patients compared to control group (3.26±1.46mg/L vs 2.16±1.28mg/L; p=0.02). In multivariate regression analysis using model adjusted for age, gender, body mas index, hypertension, diabetes mellitus, and creatinine levels, plasma resistin levels [odds ratio (OR): 1.30; 95% confidence interval (CI): 1.01-1.70; p=0.04] and hs-CRP levels (OR: 1.44; 95% CI: 1.12-1.86; p=0.004) were the only independent predictors of AF. CONCLUSION: The elevated levels of plasma resistin were related to paroxysmal AF group and persistent AF group, but not to permanent AF group.

Alzheimer's disease: is pacemaker implantation safe?

AIM: To evaluate the safety of pacemaker implantation in patients with Alzheimer's disease (AD). METHODS: We reviewed all cases admitted to our institution between January 2008 and June 2009, with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. Patients with a diagnosis of AD were included in the study. The risks and frequency of complications due to the pacemaker implantation were evaluated. Because of the older age of patients, they were divided into 2 groups to define the effect of age on complication rate. Group 1 consisted of patients aged <75 years, and group 2 consisted of those who are ≥75 years. RESULTS: Among the 574 patients with permanent pacemaker, 20 patients (3.4%) had a diagnosis of AD. Three patients with an AD experienced a complication and all were in group 2. However, the rate of complication was not significant within groups (P = 1.000). Reoperation was needed for all of them, and it was significantly higher in patients with AD than in patients without a concomitant disease (P = .006). Patients in group 2 had 3 times higher rate of complication (21.4%) than those without an AD and aged ≥75 years (7.1%; P = .125). CONCLUSION: Pacemaker implantation may be of risk in patients with AD, especially in those aged ≥75 years.

Ventricular tachycardia: first manifestation of myotonic dystrophy.

Myotonic dystrophy type 1 (DM1) is the most frequent muscular dystrophy in adults. It is a multisystem disorder also affecting the heart with an increased incidence of sudden cardiac death. We present a young female patient with ventricular tachycardia (VT) who had no cardiac complaints previously. In this patient, the phenotypic characteristics implying DM1, neuromuscular testing and genetic analysis all confirmed the diagnosis of DM1 and because of the malignant nature of VT, she received an implantable cardioverter/defibrillator.

[Primary angioplasty in women with ST-elevation myocardial infarction: in-hospital and long-term clinical results]. / ST yükselmeli miyokart enfarktüslü kadinlarda primer anjiyoplasti: Hastaneiçi ve uzun dönem klinik sonuçlar.

OBJECTIVES: We evaluated in-hospital and long-term clinical results of female patients following primary angioplasty for ST-elevation myocardial infarction (STEMI), in comparison with male patients. STUDY DESIGN: We reviewed 2,644 patients (2,188 males, 456 females) who underwent primary angioplasty for STEMI between October 2003 and March 2008. Data on female patients concerning demographic and clinical characteristics, primary angioplasty results, in-hospital and 25-month follow-up results were compared with those of male patients. RESULTS: Hypertension, diabetes mellitus, anemia, shock, and renal failure were more common in female patients, while smoking was more frequent in males (p<0.05). The mean age was higher in female patients (63.9±11.7 vs. 55.2±11.3 years, p<0.001). Females also presented with higher values of glucose, mean platelet volume, and platelet count, and lower hemoglobin and hematocrit values (p<0.05). The frequencies of multivessel disease and procedure failure were significantly higher, and pain-to-balloon time was significantly longer in females (p<0.05). Mortality associated with cardiovascular causes occurred in 148 patients (5.6%), being significantly higher in females (9.4% vs. 4.8%, p<0.001). In-hospital mortality, major cardiac events, stroke, cardiogenic shock, and major bleeding were more frequent in women (p<0.05). Long-term mortality rate was also significantly higher in females (10% vs. 4.5%, p<0.001). Multivariate analysis showed female gender as one of the independent predictors of mortality (odds ratio=1.75, 95% CI 1.02-2.99; p<0.04). CONCLUSION: Female patients with STEMI undergoing primary angioplasty have a higher risk profile and poorer in-hospital and follow-up clinical results. Therefore, female patients should be treated more aggressively.