Determining Subclinical Cardiovascular and Cardiac Diseases in Patients with Non-Alcoholic Fatty Liver Disease.

BACKGROUND: The aims of the present study were to determine the subclinical coronary atherosclerosis and myocardial dysfunction in patients with non-alcoholic fatty liver disease, who were asymptomatic for cardiac disease. METHODS: A total of 61 non-alcoholic fatty liver disease patients were enrolled in the study. The 10-year probability of cardiovascular events was evaluated according to the pooled cohort equation risk score (atherosclerotic cardiovascular disease). The coronary artery calcium score was measured. Conventional echocardiographic examination was followed by 2- and 3-dimensional speckle tracking echocardiography. RESULTS: Patients with non-alcoholic steatohepatitis had significantly higher insulin resistance (P = .018), serum alanine aminotransferase (P = .002) and aspartate aminotransferase levels (P = .021), hepatic steatosis (P = .023), and fibrosis (P = .001) than non-alcoholic fatty liver disease patients. The mean Atherosclerotic Cardiovascular Disease score was 7.5% ± 6.9% and 37% of the patients had medium and high cardiovascular disease risk. Cardiovascular disease (>1) was found in 30% of the patients. Interestingly, 56% had significant and extended atherosclerotic plaques. Among the patients with moderate-to-high atherosclerotic cardiovascular disease scores, 63% had significant atherosclerotic plaques and 21% had extensive plaque burden. The presence of non-alcoholic steatohepatitis did not significantly affect cardiovascular risk. Non-alcoholic steatohepatitis was deleterious on left ventricle diastolic functions. Mean A velocity in non-alcoholic steatohepatitis patients was significantly increased compared to non-alcoholic fatty liver disease patients (87.0 ± 17.5 cm/s vs. 72.3 ± 13.6 cm/s, P = .002). Mean E/e' ratio was 8.1 ± 2.0. Submyocardial fibrosis detected had a slightly higher occurrence in non-alcoholic steatohepatitis patients than in non-alcoholic fatty liver disease patients (P = .530). CONCLUSION: The presence of non-alcoholic steatohepatitis did not significantly increase the risk of cardiovascular disease and subclinical myocardial dysfunction in asymptomatic patients for cardiac disease compared to non-alcoholic fatty liver disease patients.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Total blush score: a new index for the assessment of microvascular perfusion in idiopathic dilated cardiomyopathy.

BACKGROUND: The aim of this study was to evaluate tissue-level perfusion in patients with idiopathic dilated cardiomyopathy (IDC), using the myocardial blush grade technique. METHOD: The study population consisted of 26 prospectively enrolled IDC patients (15 women and 11 men; mean age, 59+/-8.8 years) and 26 control subjects (11 women and 15 men; mean age, 54.9+/-10.6 years), whose angiographic films were technically adequate for myocardial blush grade analysis. After grading, we measured total blush score (TBS) for both groups. TBS was determined as the sum of the blush grades of each coronary territory. RESULTS: A total of 156 coronary territories in both groups were assessed. Average of TBS was significantly lower in patients with IDC than in control group (7.6+/-1.2 vs. 8.8+/-0.4; P<0.0001). The TBS significantly and inversely correlated with New York Heart Association class, heart rate, left ventricular end-systolic dimension, and left ventricular end-diastolic pressure, and positively correlated with left ventricular ejection fraction (r=-0.76, P<0.001; r=-0.61, P=0.001; r=-0.77, P<0.0001; r=-0.68, P<0.0001; and r=0.67, P<0.0001, respectively). CONCLUSION: In IDC, decreased TBS might be assumed to be a surrogate marker for a diseased microvascular network in the catheterization laboratory. The relationship between reduced TBS and IDC severity suggests that this index might have prognostic significance.

The impact of the distance between the atrial electrode and the atrial wall on atrial undersensing in patients with VDD pacemakers: long-term follow-up.

AIM: Atrial undersensing (AUS) in single-lead VDD pacemakers may be due to diminished P-wave amplitude secondary to local inflammation beneath the electrodes closer to atrial wall. The aim of this study was to assess the potential effect of distance between atrial electrode and atrial wall on immediate and long-term atrial sensing stability in VDD systems. METHODS: A total of 275 patients with normal sinus node function who received VDD pacemakers were enrolled into the study and were followed up for a median duration of 33 months. During each control visit, a standard 12-lead electrocardiogram (ECG) was obtained and standard pacemaker function assessment was performed including testing for pacing threshold and atrioventricular synchrony. The distance between atrial electrode and atrial wall was measured from chest X-ray. RESULTS: Of the 275 patients, AUS was detected in 59 patients. Univariate predictors of AUS were use of closely spaced bipolar ring atrial electrode (CSBR) (P = 0.01), wider atrial ring-spacing (P = 0.03), and atrial sensitivity programmed to a higher level (P = 0.001). Use of CSBR (P = 0.04) and atrial sensitivity > or =0.3 mV (P = 0.02) were observed to be the independent predictors for AUS. When the distance between atrial electrode and atrial wall was <7 mm, AUS was less with diagonally arranged bipolar ring electrodes (DABR) than it was with CSBRs (P = 0.02). CONCLUSIONS: The distance between atrial electrode and atrial wall does not appear to affect AUS incidence in VDD pacemakers. For VDD electrodes closer to atrial wall, AUS was significantly less likely in DABR-type electrodes.

Relationship between angiotensin-converting enzyme gene polymorphism and severity of aortic valve calcification.

OBJECTIVE: To investigate the role of angiotensin-converting enzyme (ACE) gene polymorphism in patients with degenerative aortic valve calcification (AVC). PATIENTS AND METHODS: Our study consisted of 305 Turkish patients of European descent (139 male, 166 female; mean plus or minus age, 68 plus or minus 9 years) referred to our echocardiography laboratory for aortic valve evaluation between June 2, 2003, and April 29, 2005. The severity of AVC was graded from 1 to 6 by echocardiography. We used polymerase chain reaction to determine ACE gene polymorphism. RESULTS: The ACE insertion/deletion genotype distributions for the study population were in Hardy-Weinberg equilibrium (chi square equals 3.5, P equals .18). The study population was divided into 3 groups based on the severity of AVC: those with grade 1 calcification were in group 1, those with grades 2 to 4 in group 2, and those with grades 5 to 6 in group 3. Group 1 patients were significantly younger, less likely to have hypertension and diabetes, and had higher high-density lipoprotein cholesterol levels. The genotype frequencies were significantly different among groups, with the insertion/insertion genotype being less prevalent in group 3 patients. In multivariate analysis, independent predictors of severe AVC were hypertension (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.8 to 11.0; P less than .001), low high-density lipoprotein cholesterol (OR, 2.7; 95 percent CI, 1.5 to 4.9; P equals .001), and the deletion/deletion and insertion/deletion vs insertion/insertion genotype (OR, 3.2; 95 percent CI, 1.5 to 7.2; P equals .004). CONCLUSION: These results suggest that ACE gene polymorphism may be associated with severe AVC.

The association between androgen levels and premature coronary artery disease in men.

OBJECTIVE: The relationship between androgens and the risk of development of coronary artery disease has not been clarified well. This study was planned to determine the relationship between serum androgen levels and premature development of coronary artery disease in men. METHODS: Sixty-nine men below 45 years of age with documented coronary artery disease (mean age 41.0+/-4.7) constituted the study group. Control group consisted of 56 men with similar age and normal coronary angiograms (mean age 41.3+/-3.8). Total and free testosterone, estradiol, and fasting plasma total, low-density lipoprotein, and high-density lipoprotein cholesterol, and triglyceride levels were measured, and compared between the two groups. RESULTS: Mean age, body mass index, and the frequency of hypertension were similar between the two groups; however, diabetes mellitus, smoking, hyperlipidemia, and family history of coronary artery disease were more frequent in the coronary artery disease group. Total and free testosterone levels of the patients with coronary artery disease were significantly lower than those of controls, whereas estradiol levels did not differ. Multivariate logistic regression analysis revealed that free testosterone levels (P=0.014; odds ratio=0.90; 95% confidence interval=0.87-0.99), hyperlipidemia (P<0.001; odds ratio=8.2; 95% confidence interval=3.17-21.0), and smoking (P=0.026; odds ratio=3.12; 95% confidence interval=1.15-8.48) were independent predictors of premature coronary artery disease. Moreover, using receiver operating characteristic analysis, patients with free testosterone levels below the cut-off value of 17.3 pg/ml had an adjusted 3.3-fold risk of developing premature coronary artery disease compared to those with free testosterone levels above the cut-off level (odds ratio=3.3; 95% confidence interval=1.57-6.87). CONCLUSION: A low level of free testosterone may be related to the development of premature coronary artery disease.

Effects of thyroxine therapy on right ventricular systolic and diastolic function in patients with subclinical hypothyroidism: a study by pulsed wave tissue Doppler imaging.

INTRODUCTION: The effects of l-thyroxine (l-T(4)) replacement for subclinical hypothyroidism (SH) on right ventricle (RV) functions has not been previously studied by means of pulsed wave tissue Doppler imaging (PWTDI). We investigated the effects of l-T(4) therapy on RV function in patients with SH using PWTDI. PATIENTS AND METHODS: Fifty-three patients with newly diagnosed SH and 25 controls were evaluated by standard echocardiography and PWTDI. After euthyroidism was restored by l-T(4), measurements were repeated. Myocardial systolic wave (S(m)) velocity, isovolumic acceleration (IVA), myocardial precontraction time (PCT(m)), and PCT(m) to contraction time (CT(m)) ratio were calculated as systolic indices. Early (E(m)) velocity, late (A(m)) velocity, E(m) to A(m) ratio, and myocardial relaxation time (RT(m)) were determined as diastolic measurements. RESULTS: S(m) was similar in patients and controls, whereas IVA was significantly lower in patients with SH (P < 0.001). SH patients had significantly decreased E(m) velocity, whereas A(m) velocity and E(m) to A(m) ratio did not differ. PCT(m) and RT(m) were significantly longer, and PCT(m) to CT(m) ratio was significantly higher in patients (P = 0.002, P = 0.002, P < 0.001, respectively). S(m) velocities were similar before and after l-T(4) replacement, whereas IVA significantly increased after therapy (P < 0.001). E(m) tended to increase (P = 0.05), whereas A(m) and E(m) to A(m) ratio were not changed. PCT(m), PCT(m) to CT(m) ratio, and RT(m) decreased significantly (P < 0.001 for all). CONCLUSIONS: SH is associated with RV systolic and diastolic dysfunction, and l-T(4) treatment improves these abnormalities. PWTDI, especially IVA, may be a suitable tool for the early detection of RV systolic dysfunction.

Second recurrence of familial cardiac myxomas in atypical locations.

Recurrence rates reported for cardiac myxomas are 4% to 7% for sporadic cases and 10% to 21% for familial cases. Although recurrence rates are high, second recurrences are rare. Familial cardiac myxomas in a mother and daughter are reported, both of whom had their second recurrences within six years. Both had recurrences in uncommon places, such as the left atrial posterior wall, between the left atrial appendage and the pulmonary vein, and the anterior mitral leaflet.

Association between proliferative scars and in-stent restenosis.

BACKGROUND: Keloid and hypertrophic scars are two types of proliferative scars at sites of cutaneous injury that form as a result of an abnormal wound-healing process. Proliferative scar formation after skin injury and restenosis after coronary stenting have common features. The aim of this study was to investigate the association of proliferative scars with coronary stent restenosis. METHODS: Patients with previous open heart surgery with median sternotomy who had coronary stenting after the surgery and were admitted for control angiography were included in the study. The patients were divided into two groups according to the presence or absence of proliferative scars. The primary end point was the incidence of angiographic restenosis in patient groups. RESULTS: The study group consisted of 80 patients (64 men; mean age 64 + or - 9 years). Twenty-three patients (29%) have a proliferative scar. In general, two groups were comparable with regard to baseline lipid profiles, demographics, and cardiovascular risk factors. Restenosis was significantly more prevalent in patients with proliferative scars than with controls (p = .04). By multivariate logistic regression analysis, stent length (odds ratio [OR] 1.12, p = .005), diabetes (OR 3.3, p = .03), and proliferative scar (OR 4.2, p = .02) independently predicted in-stent restenosis. CONCLUSION: The findings of this study suggest that patients with proliferative scars may have a higher risk of in-stent restenosis.

Value of tissue Doppler myocardial velocities of tricuspid lateral annulus for the diagnosis of right heart failure in patients with COPD.

OBJECTIVE: Aim of this study was to investigate the value of systolic indices of tricuspid valve annular motion measured by tissue Doppler imaging for the diagnosis right ventricular failure in patients with chronic obstructive pulmonary disease (COPD). METHODS: Patients with COPD with right heart failure symptoms and/or right ventricular dilatation were enrolled for the study. The control group consisted of age and sex matched patients referred to the echocardiography laboratory who had normal echocardiographic examination. Tricuspid valve annulus peak systolic velocity and myocardial acceleration during isovolumic contraction were recorded by tissue Doppler imaging. RESULTS: IVA and Sa wave velocities were found to be significantly decreased in patients with right ventricular failure. For the prediction of right heart failure IVA <3.8 m/sec2 had 91% sensitivity, 80% specificity, 90% positive predictive value (PPV), and 82% negative predictive value (NPV) and Sa wave velocity <9.2 cm/sec had 80% sensitivity, 62% specificity, 75% PPV, and 68% NPV. CONCLUSION: Tricuspid valve annular velocities measured by tissue Doppler imaging especially IVA, offer potential diagnostic value for the diagnosis of right heart failure in patients with COPD.

Two cases of quadricuspid aortic valve.

Quadricuspid aortic valve is a rare congenital malformation of the aortic valve. Most cases are discovered incidentally at autopsy or at aortic valve replacement. Recent advances in echocardiography epecially transesophageal echocardiography led to diagnosis of more cases before surgery. Two cases of quadricuspid aortic valve are presented.