The value of transient ischemic dilation for detecting restenosis after coronary artery revascularization.

AIM: Transient ischemic dilation (TID) is a marker of severe coronary artery disease (CAD). We aimed to assess the incremental value of TID in a cohort of patients with known significant CAD who had recurrence of symptoms after revascularization. METHODS: We identified in our databases 104 patients who had recent coronary revascularization and recurrence of symptoms. 62 patients had PCI (75 arteries) and 42 patients had CABG (104 arteries). All had follow-up stress SPECT MPI and repeat coronary angiography. Myocardial perfusion findings of ischemia and TID were correlated with presence of significant obstructive CAD (>70% stenosis). RESULTS: Follow-up stress Tc-99m Sestamibi SPECT MPI revealed inducible ischemia in 38 patients (36.5%) and TID > 1.20 in 49 patients (47%). Subsequent coronary angiography showed significant obstructive CAD in 44 patients (42%). The sensitivity for detecting obstructive CAD was 61% for SPECT MPI alone, but increased significantly to 93% by the addition of TID as a diagnostic criterion (P < 0.0001). CONCLUSIONS: In this selected patient cohort with prior coronary revascularization, TID is an important marker of obstructive CAD and has incremental value over SPECT MPI alone.

Serum Irisin Level Can Predict the Severity of Coronary Artery Disease in Patients with Stable Angina.

BACKGROUND AND OBJECTIVES: The recently discovered myokine irisin has a proposed role in adipose tissue metabolism. The aim of this study was to evaluate the relationship between serum irisin level and the coronary artery severity in patients with stable coronary artery disease (CAD). SUBJECTS AND METHODS: Sixty-three patients who underwent coronary angiography (CA) diagnosed with stable CAD and twenty-six patients with normal coronary artery (NCA) were enrolled in the study. Stable CAD patients were divided into two groups as high synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score (≥23) and lower SYNTAX score (<23). Serum irisin level measurement was carried out using human irisin colorimetric enzyme-linked immunosorbent assay (ELISA) commercial kit (AG-45A-0046EK-KI01, Adipogen, San Diego, CA, USA) as recommended by the manufacturer's protocol. RESULTS: The patients with stable CAD with a higher SYNTAX score (score ≥23) had significantly lower serum irisin levels (127.91±55.38 ng/mL), as compared the patients with a low SYNTAX score (score <23) (224.69±92.99 ng/mL) and control group (299.54±123.20 ng/mL). Irisin levels showed significant differences between all groups (p<0.001). CONCLUSION: Serum irisin level is an independent predictor of coronary artery severity in patients with stable CAD.

Calcific aortic stenosis and its correlation with a novel inflammatory marker, the lymphocyte/monocyte ratio.

INTRODUCTION: Calcific aortic valve disease, a chronic progressive disorder, is the leading cause of valve replacement among elderly patients. The lymphocyte/monocyte ratio has been recently put forward as an inflammatory marker of relevance in several cancers as well as in cardiovascular disease. This study aims to assess the correlation between severity of calcific aortic stenosis and the lymphocyte/monocyte ratio. METHODS: The study retrospectively included 178 patients with a diagnosis of calcific aortic stenosis and 139 age- and gender-matched controls. The patients were divided into two groups according to the severity of aortic stenosis: mild-to-moderate and severe. RESULTS: An inverse correlation was discerned between the severity of the aortic stenosis process (mean gradient) and the lymphocyte/monocyte ratio (r=-0.232, p=0.002). The lymphocyte/monocyte ratio was observed to decrease as the severity of aortic stenosis increased (p<0.001) in the group with severe aortic stenosis compared with the mild-to-moderate aortic stenosis and control groups (p<0.001, p=0.005 respectively), and in the group with mild-to-moderate aortic stenosis compared with the control group (p=0.003). Multivariate regression analysis revealed that the lymphocyte/monocyte ratio was independently related to the severity of calcific aortic stenosis (p=0.003). CONCLUSION: The present study demonstrated the existence of a statistically significant inverse relationship between severity of calcific aortic stenosis and the lymphocyte/monocyte ratio. The study also revealed that the lymphocyte/monocyte ratio was significantly related to the severity of the aortic valve stenosis process.

Evaluation of heart rate recovery index in heavy smokers.

OBJECTIVE: Cigarette smoking increases the risk of cardiovascular events. The heart rate recovery index (HRRI) is an indicator of autonomous nervous system function and is an independent prognostic risk factor for cardiovascular diseases. In this study, we aimed to evaluate HRRI in heavy smokers. METHODS: A total of 179 apparently healthy subjects (67 non-smokers as the control group and 112 heavy smokers) were enrolled into this prospective cross-sectional study. The presence of hypertension, diabetes mellitus, and known cardiac or non-cardiac diseases was specified as the exclusion criteria. Heavy cigarette smoking was defined as the consumption of more than one packet of cigarette per day. All subjects underwent the maximal Bruce treadmill test. HRRIs of the heavy cigarette smoker group at 1, 2, 3, and 5 min after maximal exercise were calculated and compared to those of the control group. Student t-test, chi-square test, and analysis of covariance were used for statistical analysis. RESULTS: The baseline characteristics of the two groups were similar, except for body mass index and high-density lipoprotein level. HRRIs at 1, 2, 3, and 5 min after maximal exercise were found to be significantly lower in the heavy smoker group (HRRI1: 26.78±8.81 vs. 32.82±10.34, p<0.001; HRRI2: 44.37±12.11 vs. 51.72±12.87, p<0.001; HRRI3: 52.73±11.54 vs. 57.22±13.51, p=0.018; and HRRI5: 58.31±10.90 vs. 62.33±13.02, p=0.029). CONCLUSIONS: In the present study, we found that HRRI was impaired in heavy smokers. Our results suggest that beside previously known untoward effects on vascular biology, heavy smoking also has deleterious effects on the neuro-cardiovascular system.

Human Endothelial Cell-Specific Molecule-1 (Endocan) and Coronary Artery Disease and Microvascular Angina.

Endothelial cell-specific molecule-1 (endocan) is an immunoinflammatory marker linked to endothelial activation and dysfunction. We investigated the relationship between obstructive coronary artery disease (CAD), microvascular angina (MVA), and plasma levels of endocan. We included 53 healthy individuals as controls, 40 MVA patients, and 120 patients with obstructive CAD. The severity of CAD was assessed by the Gensini and SYNergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery (SYNTAX) scores. Endocan levels were 382.7 (313.8-470.2) pg/mL in patients with obstructive CAD; 324.3 (277.1-460.7) pg/mL in MVA group, and 268.0 (226.4-336.5) pg/mL (P < .001) in controls. Endocan levels in obstructive CAD and MVA groups were similar but both were significantly higher than for the control group (P < .001 and P = .002, respectively). In subgroup analysis, similar to the hypertensive subgroup results, endocan was still an independent predictor of presence of obstructive CAD in normotensives (odds ratio = 1.005, 95% confidence interval = 1.001-1.010, P = .024). There was also an independent positive correlation between endocan levels and SYNTAX score both in the hypertensives (ß = 0.414, t = 3.21, P = .002) and in the normotensives (ß = .301, t = 2.23, P = .031). In conclusion, endocan could be a common predictor of the endothelium-dependent inflammatory processes, rather than related with specific risk factors.

Association Between Platelet to Lymphocyte Ratio and Saphenous Vein Graft Disease.

Atherosclerosis plays an important role in saphenous vein graft disease (SVGD). Previous trials showed that inflammatory blood cells play a role in this process. The platelet to lymphocyte ratio (PLR) has been proposed as a novel predictor for cardiovascular risk and indicator of atherosclerosis. The aim of this study was to assess the relationship between SVGD and PLR. A total of 220 patients with SVG were enrolled (n = 87 with SVGD and n = 133 with patent SVG). A ≥ 50% stenosis within the SVG was defined as clinically significant. Median PLR (P < .001) and mean platelet volume (MPV; P = .043) were significantly higher in patients with SVGD. Also, PLR showed significantly positive correlation with age of SVG (P < .05). Median age of SVGs was also higher in the SVGD group (P = .025). In multivariate logistic regression analyses, the PLR and MPV were independent predictors of SVGD. Using a cutoff level of 106.3, the PLR predicted SVGD with a sensitivity of 87.4% and a specificity of 80.3%. To the best of our knowledge, this study showed, for the first time, that PLR was independently associated with SVGD. Both PLR and MPV might predict SVGD.

Effect of Long-Term TNF-α Inhibition with Infliximab on Left Ventricular Torsion in Patients with Rheumatoid Arthritis.

INTRODUCTION: We evaluated the impact of tumor necrosis factor alpha (TNF-α) inhibition on left ventricular torsion (LVtor) in patients with rheumatoid arthritis (RA) using speckle-tracking echocardiography (STE). METHODS: Thirty-eight RA patients without cardiovascular disease and 30 healthy subjects were enrolled in the study. Twenty patients received infliximab, a monoclonal antibody against TNF-α, and 18 patients received increasing doses of prednisolone for 180 days. Global systolic longitudinal strain (G-LS), global systolic radial strain (G-RS) and global systolic circumferential strain (G-CS) were determined by STE. LV basal and apical rotations from the base and apex were obtained and used for calculation of LVtor. Pre-treatment LVtor levels were compared with LVtor levels after therapy in both treatment groups. RESULTS: RA patients had lower G-LS (-16.5 ± 2.9; p<0.01), G-RS (37.6 ± 1.5; p<0.01) and higher GCS (-23.6 ± 3.5; p=0.04) compared with control subjects (-20.0 ± 2.8, 40.7 ± 4.8, -22.4 ± 2.5, respectively; p<0.01). LVtor levels were significantly higher in RA patients compared to controls (16.4 ± 2.7 vs. 15.1 ± 2.5; p=0.04), which might be attributed to higher values of apical rotation (9.7 ± 2.4 vs. 8.8 ± 2.3; p=0.01). Patients treated with infliximab experienced a significant decrease in LVtor (p=0.04), and a significant increase in G-LS (p<0.01) and G-RS (p<0.01). No significant changes were observed among patients treated with prednisolone. Percentage changes in LVtor were correlated with percent changes in C-reactive protein CRP (r=0.58; p<0.01), disease activity score (r=0.78; p<0.01), and G-LS (r=-0.40; p=0.04) in patients treated with infliximab. CONCLUSIONS: RA is characterized by increased LVtor. Long term TNF-α inhibition improves LV longitudinal and radial systolic deformation and decreases LVtor.

Chronic inhibition of tumor necrosis factor-α with infliximab improves myocardial deformation in parallel with aortic elasticity in rheumatoid arthritis.

OBJECTIVES: This study investigated the effects of infliximab, a monoclonal antibody against TNFα, on myocardial deformation and aortic elasticity in patients with rheumatoid arthritis (RA), and the association of aortic elasticity with myocardial deformation. STUDY DESIGN: 38 female rheumatoid arthritis (RA) patients and 30 healthy controls were included in the study. Twenty patients received infliximab and 18 patients received prednisolone. Left ventricular (LV) longitudinal, circumferential and radial strain, systolic strain rate and early diastolic strain rate using speckle-tracking echocardiography, and aortic elasticity using M-mode echocardiography were assessed at baseline and post-treatment. RESULTS: LV systolic longitudinal basal-, mid-, and apical strain, systolic mid- and apical strain rate, basal-, mid- and apical early strain rate, circumferential systolic apical strain and systolic strain rate were reduced in RA patients compared to controls. Compared to baseline, infliximab treatment increased aortic strain, aortic distensibility and decreased aortic ß index. No significant aortic elastic changes were observed with prednisolone treatment. Longitudinal basal- and apical strain, basal-, mid- and apical systolic and diastolic strain rates, circumferential basal systolic strain, radial mid- and apical strain and apical strain rate were increased following infliximab treatment. Infliximab treatment improves aortic elasticity in parallel to myocardial deformation, but no significant association was observed following prednisolone treatment. CONCLUSION: Myocardial deformation is impaired in RA patients and is related to aortic stiffness. Chronic inhibition of TNFα improves LV deformation in association with aortic elasticity.

Relationship between neutrophil-to-lymphocyte ratio and saphenous vein graft disease in patients with coronary bypass.

PURPOSE: In this study, we aimed to investigate the relationship between saphenous vein graft disease (SVGD) and neutrophil-to-lympocyte ratio (NLR) with other possible confounding factors. METHODS: A total of 120 patients were enrolled into the present study. Of all participants, 40 patients were with SVGD and 80 of them were with patent SVG. RESULTS: The NLR, white blood cell (WBC) count, age of SVG, red cell distribution width (RDW), and mean platelet volume were significantly higher in the SVGD group. In regression analysis, NLR, WBC, RDW, and age of SVG remained as independent predictors of SVGD. CONCLUSION: To our knowledge, we showed for the first time that NLR is independently associated with SVGD. It can be easily used in this era, because it is easily available, widely used, and relatively cheap. Besides NLR, WBC count, SVG age, and RDW can also be used to predict SVGD.

Infliximab, an anti-TNF-alpha agent, improves left atrial abnormalities in patients with rheumatoid arthritis: preliminary results.

BACKGROUND: Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality. In the current prospective study, we addressed the impact of RA on left atrial (LA) function and electrical remodelling. Further, we tried to demonstrate the effects of infliximab, an anti-TNF-alpha agent, on echocardiographical LA abnormality in RA patients with preserved left ventricular (LV) ejection fraction. METHODS: We compared 38 female RA patients without clinical evidence of heart disease and 30 female controls without RA and clinical evidence of heart disease. Further, we compared RA patients receiving infliximab and increasing doses of prednisolone over a three-month period. At baseline and post treatment, this study assessed (1) LA and LV parameters using conventional and speckle tracking echocardiography (STE), and (2) electrocardiographic P-wave changes. RESULTS: The values of C-reactive protein (CRP), isovolumic relaxation time (IVRT), A wave, and deceleration time (DT) were significantly higher in RA patients compared to the control group (p < 0.05), whereas E/E' and E/A values were found to be lower (p < 0.05) in RA patients. E/E' values were lower in prednisolone- compared to infliximab-treated patients (p < 0.05). After three months of infliximab and prednisolone treatment, CRP and disease activity score (DAS 28) values decreased in both groups (p < 0.05), and Duke activity status index (DASI) increased (p < 0.05). Maximal left atrial volume index (LAVImax), pre-contraction left atrial volume index (LAVIpreA) and maximum P wave (Pmax) of the RA patients were higher compared to the control group (p < 0.05), whereas LA global strain was found to be lower (p < 0.05). There was no difference in Pmax values between groups before and after the treatment period. E/E', LAVImax and LAVIpreA values of infliximab-treated patients decreased and LA global strain increased after three months of therapy compared to baseline (p < 0.05). At baseline in both treatment groups, E/E' and LA global late diastolic strain rate were lower in prednisolone-compared to infliximab-treated patients (p < 0.05). CONCLUSION: There was echocardiographic LA abnormality in these RA patients. In this patient group there was also a meaningful increase in maximum P wave assessed by electrocardiography. Infliximab therapy for a period of three months improved LA abnormality.

Inadvertent complication of prosthetic valve surgery: leaflet perforation.

There are various complications of prosthetic valvular surgeries. Among them, leaflet perforation should be emphasized and brought to mind when there have been eccentric valvular regurgitation. In this report, we presented 2 cases of iatrogenic aortic and mitral valve leaflet perforation after prosthetic valve surgeries.

Subclinical atherosclerosis and hyperandrogenemia are independent risk factors for increased epicardial fat thickness in patients with PCOS and idiopathic hirsutism.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting reproductive-age women and is reported to be associated with an increased risk of cardiovascular disease and early atherosclerosis. Epicardial fat thickness (EF) is clinically related to subclinical atherosclerosis and visceral fat changes. Therefore, the objective of this study is to compare the carotid artery intima-media thickness (CIMT), EF and cardiometabolic risk factors in patients with PCOS, patients with idiopathic hirsutism (IH) and healthy controls. METHODS: This cross-sectional controlled study was conducted in a training and research hospital. The study population consisted of 50 reproductive-age PCOS women, 34 women with IH and 39 control subjects. We evaluated anthropometric, hormonal and metabolic parameters as well as CIMT and EF measurements in PCOS patients, IH patients and controls. RESULTS: The mean fasting insulin, HOMA-IR, hsCRP, GGT, CIMT, and EF levels were significantly higher in patients with PCOS and IH (p < 0.05). A significant positive correlation was found between EF and age, BMI, WHR, Ferriman Gallwey score (FG), fasting insulin, HOMA-IR, triglyceride, total cholesterol, LDL-C, 17 OH progesterone, free testosterone, CIMT, hsCRP, and GGT, whereas a significant negative correlation was observed between EF and HDL-C (p < 0.05). In the multiple linear regression analyses, EF was found to be associated with the FG (ß coefficient: 0.389, p < 0.001), CIMT (ß coefficient: 0.376, p < 0.001) and free testosterone levels (ß coefficient: 0.173, p < 0.038). CONCLUSION: EF appears to be a marker that will enable the detection of the cardiometabolic response in patients with PCOS and IH, even at an early stage.

[Percutaneous closure of a ruptured right coronary sinus of Valsalva aneurysm]. / Yirtilmis sag koroner Valsalva sinüsü anevrizmasinin perkütan yolla kapatilmasi

Sinus of Valsalva aneurysm (SVA) is a rare disease that is mostly congenital in origin. The rupture of a SVA may occur and can eventually lead to death unless definite surgical treatment occurs. In this article, a ruptured and percutaneously treated SVA in a subject who underwent two consecutive corrective open cardiac surgeries due to a congenital heart disease was examined. An 18-year-old male was referred because of the complaint of dyspnea and fatigue. He underwent a complete repair of tetrology of Fallot before and a redo-repair of residual VSD three years before. A ruptured SVA was detected by transthoracic echocardiography and aortography. Percutaneous closure was successful by an Amplatzer muscular VSD occluder. Percutaneous treatment of a ruptured SVA may be an alternative technique to surgery in selected cases.

Changes in serum natriuretic peptide levels after percutaneous closure of small to moderate ventricular septal defects.

Background. B-type natriuretic peptide has been shown to be a very sensitive and specific marker of heart failure. In this study, we aimed to investigate the effect of percutaneous closure of ventricular septal defects with Amplatzer septal occluders on brain natriuretic peptide levels. Methods. Between 2008 and 2011, 23 patients underwent successfully percutaneous ventricular septal defect closure in 4 cardiology centers. Brain natriuretic peptide levels were measured in nine patients (4 male, mean ages were 25.3 ± 14.3) who underwent percutaneous closure with Amplatzer occluders for membranous or muscular ventricular septal defects were enrolled in the study. Brain natriuretic peptide levels were measured one day before and one month after the closure. Patients were evaluated clinically and by echocardiography one month after the procedure. Results. Percutaneous closures of ventricular septal defects were successfully performed in all patients. There was not any significant adverse event in patients group during followup. Decrease in brain natriuretic peptide levels after closure were statistically significant (97.3 ± 78.6 versus 26.8 ± 15.6, P = 0.013). Conclusion. Brain Natriuretic Peptide levels are elevated in patients with ventricular septal defects as compared to controls. Percutaneous closure of Ventricular Septal Defect with Amplatzer occluders decreases the BNP levels.

Primary valvular lipomatous hamartoma: a case report and a collective review of the literature.

Cardiac valvular tumors are very infrequent lesions constituting about 10% of the primary cardiac neoplasms. Among the valvular tumors, lipomatous hamartoma represents a very rare and distinct pathological entity. Retrieval of the literature reveals only eight reported cases, and there is lack of information regarding their clinical features. Herein, we describe a patient with a mass on the tricuspid valve detected incidentally and diagnosed to be a "lipomatous hamartoma." To obtain a better understanding of the nature of these unusual lesions, we reviewed the literature and presented their clinicoanatomical characteristics together with diagnostic and therapeutic approaches.

Patent foramen ovale among patients with mild chronic obstructive pulmonary disease and unexplained hypoxia.

PURPOSE: To evaluate whether patent foramen ovale (PFO) is a contributing factor to hypoxia in patients with chronic obstructive pulmonary disease (COPD). METHODS: Twenty-one patients over 40 years of age with mild COPD (Forced expiratory volume (FEV1)/Forced Vital Capacity (FVC): > 50%) who had hypoxia (PO(2) < 80 mmHg, SaO(2) < 95%) that could not be explained by COPD alone were included in this study. Arterial oxygen pressures (PO(2)) and arterial oxygen saturations (SaO(2)) were recorded from laboratory evaluations of arterial blood gases. Respiratory function tests were performed to analyze the degree of COPD. Standard and contrast echocardiography was used to calculate pulmonary artery pressure (PAP) levels and to determine patients with a PFO. RESULTS: The mean age of the patients was 64 +/- 12 years. Four patients (19%) had a PFO. The mean PO(2), mean SaO(2), and mean PAP levels were 57.4 +/- 6.8 mmHg, 90 +/- 3.2%, and 33.8 +/- 5.4 mmHg, respectively, in patients without PFO. The mean PO(2), mean SaO(2), and mean PAP levels were 46.5 +/- 13.7 mmHg, 79.3 +/- 12.8%, and 42.5 +/- 6.5 mmHg, respectively, in patients with PFO. There were no statistically significant differences noted between the two groups in the PO(2) levels (P = 0.172) and SaO(2) levels (P = 0.065). A comparison of the PAP levels revealed a statistically significant difference between the two groups, with values that were more elevated in the PFO group than in the non-PFO group (P = 0.031). CONCLUSION: This study demonstrated that PFO is not a contributing factor to deep hypoxia in COPD patients with lower PO(2) and SaO(2) levels; however, higher PAP levels were detected in patients with a PFO. Further studies involving a larger number of patients are needed to be conclusive.

Effects of continuous positive airway pressure therapy on left ventricular function assessed by tissue Doppler imaging in patients with obstructive sleep apnoea syndrome.

AIMS: In this study, we aimed to assess left ventricular (LV) systolic and diastolic functions by tissue Doppler imaging (TDI) in patients with obstructive sleep apnoea syndrome (OSAS) and to investigate the effects of 6 month continuous positive airway pressure (CPAP) on LV systolic and diastolic functions. METHODS AND RESULTS: We studied 28 new diagnosed moderate and severe OSAS patients (apnoea-hypopnoea index >15) and 18 control group. Exclusion criteria were the presence of structural heart disease, pulmonary disease, diabetes mellitus, dyslipidaemia, alcoholism, neuromuscular disease, renal failure, or malignancy. They were not previously considered or treated for OSA and were all free of drugs. Left ventricular lateral and septal wall early myocardial peak velocity (Em), late myocardial peak velocity (Am), Em to Am ratio, myocardial relaxation time (RTm), myocardial systolic wave (Sm) velocity, isovolumic acceleration (IVA), myocardial pre-contraction time (PCTm), contraction time (CTm), and PCTm to CTm ratio were measured. All echocardiographic parameters were calculated 6 months after CPAP therapy. No statistically significant difference was detected between the groups according to age, gender, body mass index, systolic and diastolic blood pressure, heart rate, fasting blood glucose, and serum lipid parameters. Left ventricular systolic parameters, such as LV septal and lateral wall IVA, CTm, and PCTm to CTm ratio, were significantly lower and Sm was similar in patients with the OSAS group compared with the controls. Left ventricular diastolic parameters, such as LV septal and lateral wall Em velocity and Em to Am ratio, were significantly lower; RTm was significantly prolonged; and Am velocity was similar in patients with OSAS compared with the controls. At the end of the treatment, 20 of 28 patients were compliant with CPAP therapy. Left ventricular septal and lateral wall Em velocity, Em to Am ratio, IVA and CTm, and PCTm to CTm increased significantly, PCTm, PCTm to CTm ratio, and RTm decreased significantly after the therapy, whereas Sm velocity and Am velocity did not change after CPAP therapy in compliant patients. CONCLUSION: Left ventricular systolic and diastolic dysfunctions were determined in patients with OSAS, and it was demonstrated that LV systolic and diastolic dysfunctions improved with 6 month CPAP therapy.