Multiparametric assessment of right ventricular function in heart transplant recipients by echocardiography and relations with pulmonary hemodynamics.

OBJECTIVE: Right ventricular (RV) dilatation and dysfunction are usually present in heart transplant (HTx) patients and worsened with residual pulmonary hypertension (PH). We aimed to determine the ability of different echocardiographic modalities to evaluate RV function in comparison with cardiac magnetic resonance (CMR) and their relations with pulmonary hemodynamics in HTx patients. METHODS: A total of 62 data sets [echocardiographic, hemodynamic, and CMR] were acquired from 35 HTx patients. Comprehensive echocardiography, including two-dimensional (2D) transthoracic echocardiography, speckle tracking echocardiography, and three-dimensional (3D) echocardiography, was performed. Mean pulmonary artery pressure (mPAP) was obtained invasively from right heart catheterization. The correlations between all echocardiographic parameters and CMR imaging data and the differences between patients with and without residual PH were evaluated. RESULTS: Diastolic and systolic RV volumes and RV ejection fraction (RVEF) by 3D echocardiography correlated strongly with CMR-derived volumes and RVEF (r = .91, r = .79, r = .64; p < .0001 for each, respectively). Among other parameters, RV fractional area change (r = .439; p < .001) and RV free wall longitudinal strain (RVFW-LS) (r = -.34; p < .05) correlated moderately with CMR-RVEF, whereas tricuspid annulus S' velocity (r = .29; p < .05) and tricuspid annular systolic plane excursion (r = .27; p < .05) correlated weakly with CMR-RVEF. Additionally, 3D-RVEF and RVFW-LS were significantly decreased in studies with mPAP ≥ 20 mm Hg in comparison to those with mPAP < 20 mm Hg (47.7 ± 3.7 vs. 50.9 ± 5.3, p = .04 and -15.5 ± 3.1 vs. -17.5 ± 3, p = .03, respectively). CONCLUSION: The best method for the evaluation of RV function in HTx recipients is 3D echocardiography. Besides, the subclinical impact of residual PH on RV function can be best determined by RVFW-LS and 3D-RVEF in these patients.

Relation between carotid intima-media thickness, serum paraoxonase levels and severity of obstructive sleep apnea syndrome.

NTRODUCTION: Obstructive sleep apnea (OSA) has a significant effect on the development of cardiovascular complications. The aim of this study was to evaluate the relationship between carotid intima-media thickness (IMT), paraoxonase 1 (PON 1) enzyme levels and severity of OSA. MATERIAL AND METHODS: A total of 120 cases were included in the study with 30 cases in each group, as follows: Group 1 (AHI 30/h). Blood samples of the patients were taken to measure serum PON1 activity. Carotid IMT of all patients included in the study was measured by means of echocardiography using vascular probe and results were recorded. RESULTS: With regard to carotid IMT, a statistically significant increase was detected as severity of OSA increased (p < 0.001). A positive relationship was detected between IMT level and total oxygen desaturation time, oxygen desaturation index and SpO2 time < 90 % (p < 0.01). When the groups were compared, a statistically significant decline was observed in serum PON 1 level as severity of OSA increased (p < 0.05). CONCLUSIONS: The findings of our study indicate that PON1 and carotid IMT might be used as indicators of vascular damage in patients with OSA. Depending on the severity of OSA, measurement of PON1 enzyme activity in conjunction with carotid IMT may help us in predicting the cardiovascular risk in patients with OSA (Tab. 4, Fig. 2, Ref. 27).

Pulmonary Artery Distensibility is Worsened in Obstructive Sleep Apnea Syndrome.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) leads to right ventricular (RV) dysfunction and pulmonary hypertension (PH) in the later stages. Early determination of these conditions is very important. OBJECTIVES: We aimed to evaluate the correlations of pulmonary artery distensibility, right pulmonary artery fractional shortening (RPA-FS), and pulmonary artery stiffness (PAS) with PH among newly diagnosed OSAS patients. METHODS: We prospectively evaluated 34 newly diagnosed OSAS patients and 28 controls. The study subgroups were determined according to the apnea-hypopnea index (AHI). All patients underwent a transthoracic echocardiographic examination. Conventional RV parameters, PAS, and RPA-FS parameters were measured. RESULTS: RPA-FS was significantly lower in the OSAS group (p < 0.001) and positively correlated with tricuspid annular systolic excursion (TAPSE) (p = 0.047) and pulmonary acceleration time (PAT) (p = 0.006), and inversely correlated with systolic pulmonary artery pressure (sPAP) (p = 0.013), and PAS (p < 0.001). Consistent with this result, PAS was significantly worse in the patients with OSAS compared to the controls (27.1 ± 3.5 to 15.8 ± 2.7, p < 0.001), and inversely correlated with RPA-FS (p < 0.001), PAT (p = 0.001), and TAPSE (p = 0.035). PAS was positively correlated with sPAP (p = 0.001). There were statistically significant differences for both PAS and RPA-FS among the OSAS subgroups with regards to the severity of disease (p < 0.001). The correlation analyses showed a significantly positive correlation between RPA-FS and mean O2 saturation. RPA-FS was also inversely correlated with AHI. Similarly, PAS was positively correlated with AHI and arousal index. CONCLUSIONS: PAS and RPA-FS are worsened in patients with OSAS, and are correlated with PH and severity of OSAS.

The importance of the supratrochlear foramen of the humerus in humans: an anatomical study.

BACKGROUND: The supratrochlear foramen (STF) is an important and relatively common anatomic variation in the lower end of the humerus in humans. Its structure has received increased attention in recent years. Anatomical knowledge of STF is useful for anatomists, anthropologists, orthopedic surgeons, and radiologists. This aperture is of great interest to anthropologists who claim it as one of the points in establishing a relationship between humans and lower animals. The goal of this study was to describe the features of STF of the humerus in the Turkish population. MATERIAL AND METHODS: All bones were obtained from the Department of Anatomy, Faculty of Medicine and Department of Antrophology, University of Mustafa Kemal, Hatay. A total of 166 dried humeri (83 right side and 83 left side), of which 78 belonged to males and 88 to females, were examined to determine the presence of supratrochlear foramen. Digital vernier calipers were used to measure the maximum width (transverse) and height (vertical) of the STF. RESULTS: Out of 166 bones, the foramen was present in 18 humeri (4 right side and 14 left side), showing the incidence as 10.8% with unpaired humeri. We observed 4 types of shape: oval, round, triangular, and sieve-like. The average diameter of the long (transverse) axis was 5.93±1.68 mm and the short (vertical) axis was 4.06±0.89 mm. Some of the bones showed translucency of the bony septum, found in 17 (20.5%) on both sides of the humeri. CONCLUSIONS: There are few studies about STF in the Turkish population. Knowledge of supratrochlear foramen in the distal humerus in humans is important in diagnostic orthopedics, in intramedullary nailing of the humerus, and in possibly increasing the risk of future low-energy fractures. In addition, STF is a radiolucent area in radiographs and may be misinterpreted as an osteolytic or cystic lesion.

Association of epicardial adipose tissue thickness by echocardiography and hypertension.

OBJECTIVES: Epicardial adipose tissue (EAT) is a component of visceral adiposity with endocrine and paracrine effects. It is also associated with metabolic syndrome (MetS). In this study, we investigated the relationship between EAT thickness and hypertension that is a component of MetS. STUDY DESIGN: Enrolled in this study were 140 hypertensive patients and 60 age- and sex-similar normotensive controls. EAT thickness was measured using 2-D echocardiography from the parasternal long- and short-axis views. EAT thicknesses were compared between patients with hypertension and controls. The effects of hypertension on EAT thickness were evaluated like other components of MetS. RESULTS: EAT thickness was increased in hypertensive patients compared to normotensive controls (6.3 ± 1.7 mm vs. 5.3 ± 1.6 mm; p<0.001). EAT thickness correlated with systolic and diastolic blood pressures (r=0.233, p=0.001; r=0.144, p=0.047, respectively). EAT thickness was further increased in patients with uncontrolled hypertension than in those with controlled hypertension (6.6 ± 1.7 mm vs. 5.9 ± 1.8 mm, p=0.046). When linear regression analysis was performed to assess the effect of hypertension on EAT thickness like the other components of MetS, hypertension (p=0.009, 95% CI 0.236-1.619), waist circumference (p=0.003, 95%CI 0.339-1.640), HDL-cholesterol (p=0.046, 95% CI, -0.054 - 0.001) and blood glucose levels (p=0.007, 95% CI, 0.003-0.002) were found to be independent correlates of EAT thickness. CONCLUSION: EAT thickness is associated with hypertension. Hypertension could be contributing factor for the development of EAT thickness like the other components of MetS.

Approach to optimal assessment of right ventricular remodelling in heart transplant recipients: insights from myocardial work index, T1 mapping, and endomyocardial biopsy.

AIMS: Right ventricular (RV) dysfunction is an important cause of graft failure after heart transplantation (HTx). We sought to investigate relative merits of echocardiographic tools and cardiac magnetic resonance (CMR) with T1 mapping for the assessment of functional adaptation and remodelling of the RV in HTx recipients. METHODS AND RESULTS: Sixty-one complete data set of echocardiography, CMR, right heart catheterization, and biopsy were obtained. Myocardial work index (MWI) was quantified by integrating longitudinal strain (LS) with invasively measured pulmonary artery pressure. CMR derived RV volumes, T1 time, and extracellular volume (ECV) were quantified. Endomyocardial biopsy findings were used as the reference standard for myocardial microstructural changes. In HTx recipients who never had a previous allograft rejection, longitudinal function parameters were lower than healthy organ donors, while ejection fraction (EF) (52.0 ± 8.7%) and MWI (403.2 ± 77.2 mmHg%) were preserved. Rejection was characterized by significantly reduced LS, MWI, longer T1 time, and increased ECV that improved after recovery, whereas RV volumes and EF did not change MWI was the strongest determinant of rejection related myocardial damage (area under curve: 0.812, P < 0.0001, 95% CI: 0.69-0.94) with good specificity (77%), albeit modest sensitivity. In contrast, T1 time and ECV were sensitive (84%, both) but not specific to detect subclinical RV damage. CONCLUSION: Subclinical adaptive RV remodelling is characterized by preserved RV EF despite longitudinal function abnormalities, except for MWI. While ultrastructural damage is reflected by MWI, ECV, and T1 time, only MWI has the capability to discriminate functional adaptation from transition to subclinical structural damage.

Association between cardiac functional capacity and parameters of tissue Doppler imaging in patients with normal ejection fraction.

OBJECTIVE: Patients with normal ejection fraction (EF) by conventional echocardiography may present with symptoms and findings of decreased cardiac functional capacity. We aimed to investigate the association between cardiac functional capacity determined by cardiopulmonary exercise test (CPET) and parameters of tissue Doppler (TD) imaging in patients with normal EF. METHODS: In all, 52 patients with normal EF were included. Conventional and TD imaging were performed. Peak systolic (S), early (E') and late (A') diastolic velocities were obtained from septal and lateral mitral annulus and tricuspid annulus by pulsed-wave TD. CPET was performed. Exercise time, peak oxygen consumption (peak VO2), anaerobic threshold (AT), metabolic equivalents (MET) values were determined and were compared with TD imaging parameters. RESULTS: We did not find any association between conventional echocardiographic measurements and cardiac functional capacity. However, peak S, E' and A velocity from the septal and tricuspid annulus and E' velocity from the lateral annulus correlated with exercise time, peak VO2, AT and MET (all P < 0.05). E/E' from the left ventricle correlated inversely with exercise time, peak VO2, AT and MET (all P < 0.05). S, E, A' velocities from septal and tricuspid annulus, E' velocity from lateral annulus were lower in patients with MET < or = 7 than in patients with MET > 7 (all P < 0.05). CONCLUSION: Systolic and diastolic velocities measured byTD imaging correlated with cardiac functional capacity as determined by CPET in patients with normal EF by conventional echocardiography. TD imaging could be more susceptible to determine cardiac functional capacity in these patients.

Increased serum gamma-glutamyltransferase activity in patients with metabolic syndrome.

OBJECTIVES: Accumulating data indicate that serum gamma-glutamyltransferase (GGT) activity represents a true marker of atherosclerotic cardiovascular disease and has prognostic importance. In this study, we sought to evaluate serum GGT activity in patients with metabolic syndrome (MetS). STUDY DESIGN: We enrolled 232 patients (mean age 60.4 years) from our outpatient cardiology clinic, 117 with and 115 without MetS (control group) as defined by the ATP-III criteria. The results of serum liver function tests including serum GGT and C-reactive protein (CRP) levels were compared between the two groups. RESULTS: The two groups were similar with regard to age, sex, smoking, and family history of coronary artery disease (p>0.05). The prevalences of hypertension and dyslipidemia were significantly higher in patients with MetS. Compared with controls, patients with MetS had significantly higher serum GGT [(median 21, interquartile range (16-33) vs. 19 (14-26) U/l; p=0.008] and C-reactive protein levels [6.2 (3.6-9.4) vs. 5.0 (3.1-7.0) U/l; p=0.044]. A high GGT activity (>40 U/l) was determined in 14.5% of the patients with MetS and in 4.4% of the control subjects (p=0.012). Serum GGT level showed significant correlations with MetS (r=0.24, p=0.001), CRP (r=0.20, p=0.003), triglyceride (r=0.18, p=0.006), HDL cholesterol (r=-0.19, p=0.004), aspartate aminotransferase (r=0.15, p=0.02), alanine aminotransferase (r=0.32, p=0.001), and alkaline phosphatase (r=0.16, p=0.01). This significant association continued only for MetS (ß=-0.25, p=0.03), HDL cholesterol (ß=-0.18, p=0.03), and alkaline phosphatase (ß=0.17, p=0.01) in multivariate regression analysis. CONCLUSION: Our findings suggest that patients with MetS have higher serum GGT and CRP levels compared with controls. This increased GGT level might be a marker of increased oxidative stress and premature atherosclerosis.

Longitudinal Strain and Strain Rate for Estimating Left Ventricular Filling Pressure in Heart Transplant Recipients.

Traditional parameters have limited value to estimate left ventricular filling pressure (LVFP) in orthotropic heart transplant (OHT) recipients. We hypothesized that global longitudinal strain (GLS), diastolic, and systolic strain rate (SR) would be depressed in OHT recipients with elevated LVFP and could overcome the limitations of traditional parameters. We studied consecutively OHT patients at the time of endomyocardial biopsies and retrospectively pretransplantation studies conforming to the same protocol. Comprehensive echocardiography with strain measurements was performed. Results were compared with pulmonary capillary wedge pressure (PCWP) obtained from right heart catheterization that was performed just after the echocardiography study. In all, 74 studies were performed in 50 OHT recipients. Mean PWCP was 11.8 ± 4.3 mm Hg (range: 4 to 25 mm Hg). Several parameters, but not left atrial volume index, mitral inflow velocities, annular velocities, and their ratio (E/e'), were different between studies with normal (n = 47) and elevated PCWP (n = 27). Area Under Curve for GLS (0.932*), E/e'SR (0.849*), and systolic SR (0.848*) (*p <0.0001) were more accurate than traditional parameters for predicting PCWP>12 mm Hg. GLS, systolic SR and E/e'SR remained accurate regardless of LV ejection fraction and allograft vasculopathy. Meanwhile, E/e' was accurate to predict PWCP in native failing hearts before transplantation. Changes in GLS and E/e'SR tracked accurately changes in PCWP. In conclusion, traditional indices of diastolic function perform poorly in OHT recipients, whereas GLS and E/e'SR provide reliable means of LVFP, irrespective of ejection fraction and allograft vasculopathy. These parameters also track reasonably well the changes in LVFP.

Risk factors for left atrial appendage thrombus.

Background: Atrial fibrillation (AF) is the most common persistent rhythm disorder that has been shown to be associated with a significant increase in stroke risk. Left atrial appendage (LAA) thrombi are responsible for most of strokes of cardiac origin. CHA2DS2-VASc is a risk scoring system to identify patients' indications for anticoagulation in nonvalvular AF patients. The aim of our study was to investigate CHA2DS2-VASc score, the other risk factors, echocardiographic data and blood parameters for LAA thrombus.Methods: Two hundred and sixty-four patients who were admitted to our adult cardiology outpatient clinic and who underwent a transesophageal echocardiography procedure between June 2017 and June 2019 included in our study. Patient's demographic data, transthoracic echocardiographic examinations, and laboratory results were recorded retrospectively.Results: LAA thrombus was detected in 39 (14.7%) patients. The rates of coronary artery disease and systolic dysfunction were significantly higher in patients with LAA thrombus (p = .017, p = .016, respectively). When AF subtypes were examined in detail, thrombus rate was significantly higher in persistent AF (51 vs. 25.7%, p = .002). Although the CHA2DS2-VASc score was slightly higher in the thrombus group, there was no statistically significant difference between the two groups (3.0 ± 1.65 vs. 2.78 ± 1.66).Conclusions: In conclusion, CHA2DS2-VASc score system itself was not informative about LAA thrombus formation although some of its components were related with LAA thrombus formation. According to a multiple regression analysis, the independent determinants of LAA thrombus were the presence of AF and coronary artery disease.

Association of serum adiponectin levels and coronary flow reserve in women with normal coronary angiography.

BACKGROUND: Women may have atypical clinical presentations and atypical risk factors of coronary artery disease. Adiponectin has anti-insulin-resistant properties and antiatherogenic effects. We investigated the association between serum adiponectin levels and coronary flow reserve (CFR) in women with normal coronary arteries. METHODS: CFR was assessed in 45 consecutive women (mean age 54.2+/-9.2 years) with normal epicardial coronary arteries by coronary angiography. Serum adiponectin, C-reactive protein, insulin, and glucose levels were examined and Homeostasis Model Assessment for Insulin Resistance index was calculated. Peak diastolic coronary flow velocities were measured in distal left anterior descending artery at baseline and after dipyridamole infusion by transthoracic pulsed wave Doppler echocardiography. CFR was calculated as the ratio of hyperemic to baseline peak diastolic velocities. A CFR value > or =2 was accepted as normal. RESULTS: Adiponectin levels were lower in patients with impaired CFR than those with normal CFR (7.1+/-2.3 vs. 13.8+/-6.7 microg/ml P<0.001). Adiponectin levels were correlated with CFR (r=0.531, P<0.001) and inversely correlated with C-reactive protein (r=-0.308, P=0.047), insulin (r=-0.426, P=0.008), and Homeostasis Model Assessment for Insulin Resistance index (r=-0.442, P=0.004). Adiponectin levels of < or =8.5 muU/ml had 83% sensitivity and 93% specificity [receiver operating characteristic area 0.084, P<0.001, 95% confidence interval (0.56-1.08)] for predicting impaired CFR. CONCLUSION: Decreased adiponectin levels are associated with impaired CFR in women with normal epicardial coronary arteries and hypoadiponectinemia may be a risk factor for impaired CFR in women.

Serum levels of C-reactive protein and uric acid in patients with cardiac syndrome X.

OBJECTIVES: Angina-like chest pain, a positive result from a stress test, and normal coronary arteries are characteristics of patients with cardiac syndrome X (CSX). Serum levels of C-reactive protein (CRP), which is a marker of a systemic inflammatory state, are associated with coronary atherosclerosis and endothelial dysfunction. Serum uric acid (UA) levels have also been implicated in the development of atherosclerotic cardiovascular disease. However, little is known about the association of serum UA and CRP levels with CSX. METHODS: In all, 250 subjects (100 patients with CSX, 100 with coronary artery disease (CAD), and 50 control subjects) were enrolled in the study. Coronary arteries were evaluated by conventional coronary angiography in the CSX and CAD groups. All patients underwent a noninvasive stress test. To determine whether they are potential risk factors for CSX, serum CRP and UA levels were compared among the 3 groups. RESULTS: Serum levels of CRP were higher in patients with CSX or CAD than in the control subjects (4.4 +/- 3.1 and 4.5 +/- 2.9 mg/L, respectively, vs. 1.9 +/- 1.6 mg/L; P < 0.001), but those levels were similar in patients with CSX or CAD. Uric acid levels were higher in patients with CSX or CAD than in the control subjects (5.5 +/- 1.1 mg/dl and 5.9 +/- 1.4 mg/dl, respectively, vs. 4.4 +/- 1.2 mg/dl; P < 0.00 1), but those levels were also similar in patients with CSX or CAD. CONCLUSIONS: In patients with CSX, serum CRP and UA levels were as high as those in patients with CAD. Elevated serum CRP and UA levels may contribute to the development of CSX.

A case of myotonic dystrophy presenting with ventricular tachycardia and atrial fibrillation.

Myotonic dystrophy type 1 (MD1) is an autosomal dominant disorder characterized by myotonia, progressive muscular weakness, cataract, and cardiac involvement. Cardiac involvement is common and includes conduction system abnormalities, supraventricular and ventricular arrhythmias, and less frequently, myocardial dysfunction and ischemic heart disease. A 54-year-old woman with a previous diagnosis of MD1 was admitted with palpitation, blood pressure of 157/118 mmHg, and a heart rate of 220 beats/min. Electrocardiography (ECG) showed ventricular tachycardia. Within minutes, hemodynamic collapse developed and electrical cardioversion was performed. Immediately following cardioversion, ECG showed atrial fibrillation, a slightly prolonged QT interval, and intraventricular conduction delay. After intravenous infusion of amiodarone, the rhythm converted to sinus. Transthoracic echocardiography showed significantly depressed left ventricular function, an ejection fraction of 25%, and normal coronary arteries. During electrophysiological study, atrium-His interval and His-ventricle interval were 120 msec was 54 msec, respectively, and monomorphic ventricular flutter was induced. An implantable cardioverter-defibrillator was placed. She was discharged in sinus rhythm.

Decreased coronary flow reserve in obese women.

OBJECTIVES: Obesity is associated with an increased rate of cardiovascular disease and risk factors. It is a common problem in apparently healthy women. We aimed to investigate the association between obesity and coronary flow reserve (CFR) in obese women. STUDY DESIGN: The study included 80 consecutive women (mean age 55.6+/-10.2 years) without diabetes mellitus and clinical coronary artery disease. Body mass index (BMI) was calculated and obesity was defined as BMI = or >30 kg/m(2). Based on BMI, the patients were grouped as normal weight (n=13; 18.5-24.9 kg/m(2)), overweight (n=32; 25-29.9 kg/m(2)), obese (n=32; = or >30-39.9 kg/m(2)), and morbid obese (n=3; = or > 40 kg/m(2)). Peak diastolic coronary flow velocities were measured in the distal left anterior descending artery by transthoracic pulsed wave Doppler echocardiography at baseline and after dipyridamole infusion and CFR was calculated as the ratio of hyperemic to baseline peak diastolic velocities. RESULTS: There were 35 obese women (43.8%). Coronary flow reserve was significantly lower in obese women than in nonobese subjects (2.2+/-0.5 vs. 2.5+/-0.4; p=0.022). The lowest CFR was seen in patients with a BMI of = or > 40 kg/m(2); overweight women did not differ significantly from women of normal weight. Coronary flow reserve was correlated with BMI (r=-0.314, p=0.005), waist circumference (r=-0.316, p=0.005), C-reactive protein (CRP) (r=-0.342, p=0.011), and adiponectin level (r=0.410, p=0.011). In regression analysis, BMI (p=0.017), waist circumference (p=0.048), systolic blood pressure (p=0.025), fasting glucose (p=0.035), and adiponectin level (p=0.037) were found to be independent predictors for impaired CFR. In ROC analysis, the cut-off value for BMI to predict impaired CFR was = or > 30 kg/m(2), with 76% sensitivity and 72% specificity (ROC area 0.805, p<0.001, 95% CI 0.669-0.96). CONCLUSION: Impaired CFR in obese women suggests the presence of microvascular dysfunction. Treatment of obesity is important for the prevention of atherosclerosis.

T1 Mapping by Cardiac Magnetic Resonance and Multidimensional Speckle-Tracking Strain by Echocardiography for the Detection of Acute Cellular Rejection in Cardiac Allograft Recipients.

OBJECTIVES: The aim of this study was to test the hypothesis that echocardiographic strain imaging, by tracking subtle alterations in myocardial function, and cardiac magnetic resonance T1 mapping, by quantifying tissue properties, are useful and complement each other to detect acute cellular rejection in heart transplant recipients. BACKGROUND: Noninvasive alternatives to endomyocardial biopsy are highly desirable to monitor acute cellular rejection. METHODS: Surveillance endomyocardial biopsies, catheterizations, and echocardiograms performed serially according to institutional protocol since transplantation were retrospectively reviewed. Sixteen-segment global longitudinal strain (GLS) and circumferential strain were measured before, during, and after the first rejection and at 2 time points for patients without rejection using Velocity Vector Imaging for the first part of the study. The second part, with cardiac magnetic resonance added to the protocol, served to validate previously derived strain cutoffs, examine the progression of strain over time, and to determine the accuracy of strain and T1 measurements to define acute cellular rejection. All tests were performed within 48 h. RESULTS: Median time to first rejection (16 grade 1 rejection, 15 grade ≥2 rejection) was 3 months (interquartile range: 3 to 36 months) in 49 patients. GLS and global circumferential strain worsened significantly during grade 1 rejection and ≥2 rejection and were independent predictors of any rejection. In the second part of the study, T1 time ≥1,090 ms, extracellular volume ≥32%, GLS >-14%, and global circumferential strain ≥-24% had 100% sensitivity and 100% negative predictive value to define grade ≥2 rejection with 70%, 63%, 55%, and 35% positive predictive values, respectively. The combination of GLS >-16% and T1 time ≥1,060 ms defined grade 1 rejection with 91% sensitivity and 92% negative predictive value. After successful treatment, T1 times decreased significantly. CONCLUSIONS: T1 mapping and echocardiographic GLS can serve to guide endomyocardial biopsy selectively.

Serum gamma-glutamyl transferase activity: new high-risk criteria in acute coronary syndrome patients?

In acute coronary syndromes (ACS), oxidation and inflammation have very important roles and in-vitro studies have demonstrated that gamma-glutamyl transferase (GGT) participates in such oxidative and inflammatory reactions. We aimed to evaluate the prognostic value of baseline serum GGT activity on the development of major adverse cardiac event (MACE) in the follow-up of the patients with ACS in coronary care unit (CCU), after 1 and 6 month periods. We included 117 patients (mean age: 61.2+/-11.3 years, 93 males) hospitalized in CCU with the diagnosis of ACS. All had baseline serum GGT activity and were free of systemic and hepatobiliary disease. MACE was defined as the composite of mortality from cardiac causes, recurrent hospitalization with ACS and nonfatal recurrent myocardial infarction diagnoses, to need for coronary revascularization during CCU, over 1 and 6 month follow-up periods. During the follow-up of CCU, MACE occurred in 17 (14.5%) patients (two died). Serum GGT activity was significantly higher in the patients with MACE than those free of MACE (P=0.001) and GGT was found as the independent predictor of the development of MACE-CCU [relative hazard: 1.05, 95% confidence interval (CI): 1.01-1.09, P=0.007]. During the follow-up of 1 month, MACE occurred in 23 (20.0%) patients (five died). Serum GGT activity was significantly higher in patients with MACE than those free of MACE (P=0.021) and GGT was found as the independent predictor of the development of MACE-1 month (relative hazard: 1.04, 95% CI: 1.01-1.08, P=0.039). During the follow-up of 6 months, MACE occurred in 24 (21.8%) patients (two died). Again, GGT was significantly higher in patients who developed MACE than those free of MACE (P=0.001) and GGT was found as the independent predictor of the development of MACE-6 months (relative hazard 1.06, 95% CI: 1.03-1.10, P<0.001). Serum GGT activity was found to be an independent predictor of the development of MACE in the patients with ACS during CCU, over 1 and 6 month follow-up periods.

Echocardiographic diagnosis of left ventricular-right atrial communication (Gerbode-type defect) in an adult with chronic renal failure: a case report.

Left ventricular-right atrial communication, known as a Gerbode-type defect, is a rare form of ventricular septal defect. It is usually congenital, but rarely acquired. Clinical presentation is associated with the volume of the shunt. Transthoracic echocardiography is the most useful diagnostic method. We present a 63-year-old man with chronic renal failure and left ventricular-right atrial shunt.