Treatment of an unusual complication of transfemoral TAVI with a new technique: successful occlusion of ventricular septal defect by opening the closure device in the ascending aorta.

Ventricular septal defect (VSD) is a rare complication of transcatheter aortic valve implantation (TAVI) via the transfemoral approach. Aetiological factors leading to VSD have been reported as post-balloon dilatation, oversized prosthesis implantation, and severe calcification of the aorta. However, we present a case of VSD occurring after TAVI with an Edwards Sapien XT prosthesis without any distinct aetiological factors. We used a new technique for closure of the significant VSD; opening the left ventricular disc of the closure device in the ascending aorta and successfully implanting the device without any damage to the bioprosthetic valve.

The gap between the current dyslipidemia guidelines and the physicians' treatment targets in patients with type 2 diabetes in Turkey.

AIM: Lipid-lowering therapy (LLT) is a key factor in the prevention of cardiovascular mortality and morbidity in diabetic patients. Current guidelines have expanded the population of patients with diabetes for whom aggressive low-density lipoprotein cholesterol (LDL-C) lowering therapy should be considered. This study evaluated the management of dyslipidemia in patients with type 2 diabetes in real life. METHODS: Secondary care physicians in a tertiary center recruited 707 patients. The prevalence of statin use along with the achievement of cholesterol targets, predictors for receiving statin, and possible reasons for lack of therapy were investigated. RESULTS: Only 33% of the patients had received statin therapy, and this was significantly higher in those with cardiovascular disease (47% versus 27%; P<0.001). Most of the patients had LDL-C levels of >100 mg/dL (77%), with only 5% having LDL-C levels of <70 mg/dL. Forty-one percent of the patients had never been prescribed LLT previously while 26% had been prescribed this type of therapy in the past but had stopped using it. The most frequent reason for discontinuation of the statin therapy was a physician's advice to stop the medication. The patients taking statins had similar LDL-C levels as those who had never been prescribed statins and those who had discontinued their use of statins on the advice of a physician. CONCLUSION: The majority of diabetic patients are undertreated with statins and minority of them achieve LDL-C target levels. Our findings suggest that there is a large discrepency between evidence-based recommendations and physicians' treatment attitudes.

The effect of conversion type on P wave dispersion in patients with atrial fibrillation.

AIM: The aim of this study was to investigate whether conversion type of atrial fibrillation (AF) to sinus rhythm affects the P wave dispersion (PD) in patients with AF. METHODS: Based on conversion type, 95 consecutive patients with AF<3 months were divided into 3 groups: spontaneous cardioversion (SC) (N.=33, mean age: 60.6+/-11.6 years), pharmacologic cardioversion (PC) (N.=32, mean age: 59.2+/-9.6 years) and electrical cardioversion (EC) (N.= 30, mean age: 65.3+/-10.6 years). P wave duration (maximum and minimum) were measured in 12-lead ECG, and PD was calculated. RESULTS: Left atrial diameter and AF duration were significantly higher in EC (43.6+/-4.8 mm and 794.1+/-815.1 h) than SC (38.5+/-3.9 mm and 13.8+/-18.3 h) and PC (40.9+/-4.5 mm and 65.3+/-148.5 h) groups (P<0.01). P maximum was much longer in EC group compared with SC and PC group (121.6+/-9.7, 108.4+/-6.4 and 115.8+/-8.6 ms, P=0.01, respectively). There was a significant difference in PD among SC, PC and EC groups (44.4+/-9.2, 49.5+/-8.7 and 53.5+/-8.8 ms; P=0.005, respectively). PD correlated with AF duration (r=0.36, P=0.03), left atrial diameter (r=0.45, P=0.002) and conversion type (r=0.29, P=0.03). However, there was no significant association between PD and conversion type in multivariate analysis. The prolonged PD resulted from AF duration (P=0.01) and the left atrial size P=0.001). CONCLUSION: This study suggests that conversion type of AF to sinus rhythm has no effect on P wave duration and independent of AF duration and the left atrial diameter.

A unique case of anomalous coronary origin detected by 64-row multislice computed tomography coronary angiography.

The anomalous origin of the left coronary artery from the right sinus of valsalva is an anatomical abnormality that is usually associated with myocardial ischaemia and sudden death. We report on a case in which three different diagnostic techniques were used to find the cause of the ischaemic symptoms in a patient whose left coronary artery originated anomalously in the right sinus of valsalva and followed a course between the aorta and the pulmonary trunk. The techniques were treadmill exercise test for ischaemia, conventional angiography, which was used for the initial diagnosis, and 64-row multislice computerised tomography, used to determine the anomalous course of the artery.

Effect of levosimendan on right ventricular systolic and diastolic functions in patients with ischaemic heart failure.

OBJECTIVES: Levosimendan is a novel positive inotropic calcium sensitiser agent used in acute left heart failure. In this study, the effect of levosimendan on the right ventricular systolic and diastolic functions was evaluated by tissue Doppler comparing them with dobutamine in patients with ischaemic heart failure. METHODS: Patients having an acute decompensated heart failure with ischaemic cardiomyopathy and left ventricular ejection fraction <40% were included in the study. Before and 24-h after treatment, peak systolic (Sa), peak early (Ea), peak late (Aa) diastolic annular velocities and Ea/Aa ratio from tricuspid lateral annulus by tissue Doppler and systolic pulmonary artery pressure (SPAP) were measured. RESULTS: Sa, Ea and the Ea/Aa ratio were significantly increased in the levosimendan group whereas SPAP was significantly reduced. In the dobutamine group, no significant differences were observed in the Sa, Ea, Aa and Ea/Aa ratio in spite of a significant reduction in SPAP. Decrease in SPAP was greater in the levosimendan group (p=0.002). CONCLUSION: Levosimendan improves right ventricular systolic and diastolic functions.

Seasonal variability of acute myocardial infarction in a Western Anatolian city and its relations to acute infections and climate.

AIM: Some studies suggest that changes in climate may increase the rate of acute infections and also acute myocardial infarction (AMI). However, regional, cultural and ethnical differences may cause changes in seasonal distribution of AMI. In this study, we aimed to investigate the associations between AMI and acute upper respiratory tract infection (ARTI) and changes in climate in Turkish population. METHODS: In this study, we included 1 312 patients hospitalized with the diagnosis of AMI and 13 561 patients diagnosed with ARTI in our hospital. The changes of temperature and humidity of the city was obtained as average of the month. The data were matched statistically. RESULTS: Patients with ARTI showed significant seasonal variability. Although the frequency of AMI was higher in winter than other seasons, it was not statistically significant. There is a linear correlation between ARTI and AMI, and also between humidity and the incidence of AMI, and an inverse correlation between air temperature and the rate of AMI in Usak city in Turkey. CONCLUSION: This study revealed that ARTI is associated with an increased risk of AMI and it is also true for Turkish population, but there is no significant seasonal variability of AMI in Turkish population. Furthermore, no significant correlations have been found between AMI and ARTI, air temperature and humidity in female patients. These results may be related to the fact that most of the women are housewives, not facing outside climate changes in Turkish population.

Brucella pancarditis with dissecting aortic root abscess, left ventricular pseudoaneurysm and ventricular septal defect.

A rare case of Brucella pancarditis is reported in a 38-year-old male farmer who presented with heart failure. Brucella pancarditis was diagnosed with positive serology, and echocardiographic examination showed pericardial effusion, vegetation and mycotic aneurysms on the aortic root. The development of a fistula between the aorta and right ventricle, aortic dissection, a subaortic ventricular septal defect, and left ventricular pseudoaneurysm were observed. This case illustrates that life-threatening cardiac complications may develop, even under aggressive antibiotic therapy. It is recommended that echocardiographic follow-up and close collaboration between colleagues working in infectious disease, cardiology and cardiovascular surgery are crucial in the treatment of Brucella pancarditis.

Alcohol and acute myocardial infarction.

A number of studies from different countries and several large-scale meta-analyses have reported reduced coronary heart disease rates among those regularly consuming mild to moderate amounts of alcohol compared with those abstaining from alcohol. In contrast, various studies have also reported that heavy alcohol consumption promotes the progression of atherosclerosis and that binge drinking might trigger embolic stroke and acute myocardial infarction. We discuss the association between alcohol consumption and acute myocardial infarction on the basis of evidence from literature published recently. Alcohol consumption has both favourable and unfavourable effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone depending on the amount of alcohol consumed and the way that it is drunk (i.e. drinking habits). We conclude that it is extremely important to warn people of the risks associated with binge drinking and to encourage them to remain within the recommended safe limits for alcohol consumption.

Ocular bleeding related to warfarin anticoagulation in patients with mechanical heart valve and atrial fibrillation.

We investigated the incidence of ocular bleeding in patients taking anticoagulant therapy (warfarin) and its association with other related factors. We examined 210 patients taking warfarin and 210 gender- and age-matched controls for ocular bleeding. Patients and controls were examined by external ocular examination and fundoscopic examination. The incidence of ocular bleeding was 11.4% in patients and 3.8% in controls. It was five times higher in patients with hypertension than in other patients. The incidence of ocular bleeding was higher in older than in younger patients. No association was found between ocular bleeding and factors such as gender, international normalized ratio, duration of warfarin therapy, concomitant aspirin use and diabetes mellitus. Thus, warfarin therapy increases the frequency of ocular bleeding. The higher incidence of ocular bleeding in the patients with hypertension and advanced age should be kept in mind and this subgroup of patients taking warfarin should be monitored closely.

Late ventricular arrhythmias in patients with mechanical heart valves and their relation to associated factors.

AIM: Sudden death is a well known complication of prosthetic heart valve disease. Complex ventricular arrhythmias have been suggested as the cause of this event in part. In this study, we aimed to investigate the incidence and severity of complex ventricular arrhythmias in patients with mechanical heart valves and the relations between complex ventricular arrhythmias and patient and prosthetic valves related factors. METHODS: Two hundred and one patients with mechanical heart valve were included in this study. All patients were examined with transthoracic echocardiography, 24 h ambulatory electrocardiography and history including age and gender of patients, type, location, number and duration of prosthesis. Left and right heart chamber dimensions, wall thicknesses were measured and ejection fractions were calculated. Ventricular arrhythmias were classified according to Lown's classification. Grade 3 and 4 were accepted as significant and complex ventricular arrhythmias. RESULTS: Ventricular arrhythmias and complex ventricular arrhythmias were found in 64% and 34% of patients, respectively. Complex ventricular arrhythmias were not associated with gender, location, type, and number of prosthesis. Age (P=0.003), duration of prosthesis (P=0.003), left ventricular hypertrophy (P<0.001), dilatation (P<0.001), ejection fraction (P<0.001), wall-motion abnormalities (P=0.012) and right ventricular hypertrophy (P=0.026), dilatation (P=0.013), ejection fraction (P=0.003) were significantly related to complex ventricular arrhythmias. CONCLUSIONS: This study suggests that early valve replacement before cardiac anatomy critically impairs may decrease the incidence of complex ventricular arrhythmias. However, the longer duration of prosthesis may cause the more complex ventricular arrhythmias. This may reveal some controversy about the timing of surgery.

Echocardiographic and clinical abnormalities in patients with psoriasis.

We investigated the incidence and severity of echocardiographic and clinical abnormalities in patients with psoriasis and their relationship to the severity, duration and type of psoriasis and other related factors. A total of 216 psoriasis patients and 216 control subjects were included in this study. Left and right heart dimensions, wall thicknesses, wall motion abnormalities, valvular disturbances, and systolic and diastolic functions were examined using two-dimensional and Doppler echocardiographic techniques. Left ventricular hypertrophy, left ventricular diastolic dysfunction, left ventricular wall motion abnormalities and valvular pathologies, especially mitral and tricuspid valve prolapse, were significantly more frequent in patients with psoriasis. Systolic and diastolic blood pressures were significantly higher in psoriasis patients. Significant correlations were found between: (i) psoriasis vulgaris and tricuspid valve prolapse; (ii) palmo-plantar psoriasis and valvular pathologies; and (iii) disease duration and left ventricular diastolic dysfunction and systolic and diastolic blood pressures. Physicians should be aware that cardiovascular abnormalities are common in patients with psoriasis.

Must antidysrhythmic agents be given to all patients with new-onset atrial fibrillation?

We investigated the spontaneous conversion rate of new-onset atrial fibrillation (AF) in emergency department patients and the recurrence rate of AF during a 1 month follow-up period. Sixty-six consecutive hemodynamically stable patients presenting to a university hospital emergency department with new-onset atrial fibrillation (less than 72 hours duration) comprised the study population. Patients were initially monitored for 8 hours and observed for spontaneous conversion of AF to sinus rhythm. If conversion did not occur in the first 8 hours, an oral loading dose (600 mg) of propafenone was given, and patients were observed for an additional 8 hours. All patients were reevaluated at 24 hours and at 1 month. The spontaneous conversion rate in patients presenting within 6 hours of AF onset during the initial 8-hour observation period was 71%. The spontaneous conversion rate for all patients during the initial observation period was 53%. The conversion rates between patients presenting "early" (less than 6 hours) and "late" (7-72 hours) were significantly different (P < 0.001). Many patients with new-onset AF, especially those with atrial fibrillation duration less than 6 hours, may need observation only, rather than immediate intervention, to treat their dysrhythmia.

Catheter-induced vasospasm in the right external iliac and femoral arteries during a cardiac diagnostic procedure.

Catheter-induced vasospasm of small caliber arteries, such as the coronary arteries, is frequently observed during cardiac catheterization, but obstruction of the large caliber arteries has not previously been reported. Here we present two cases in which femoral and external iliac arteries were totally obstructed due to spasm during diagnostic coronary angiography.

Use of intraventricular dispersion of the peak diastolic flow velocity as a marker of left ventricular diastolic dysfunction in patients with atrial fibrillation.

The aim of this study was to evaluate the use of intraventricular dispersion of the peak diastolic flow velocity as a marker of left ventricular diastolic dysfunction in patients with atrial fibrillation. Regional diastolic flow velocity patterns at 1, 2, and 3 cm away from the mitral tip toward the apex were simultaneously recorded with the mitral flow velocity pattern by using pulsed Doppler echocardiography in 24 patients with atrial fibrillation before electrical or medical cardioversion. Echocardiographic examination was repeated after 10 to 30 days (ie, at the time of recovery of left atrial mechanical functions) after cardioversion of atrial fibrillation in all patients. Thirteen patients were found to have diastolic dysfunction; the remaining 11 patients with a normal E/A ratio constituted the control group. Afterward, the data recorded before the cardioversion were analyzed for each patient. In subjects with normal diastolic function, the peak diastolic flow velocity (PDFV) at the mitral tips also was maintained at the positions 1 to 3 cm away from the tip in the left ventricular cavity (PDFV at the mitral tips: 0.84 m/s, PDFV at 3 cm: 0.85 m/s; P =.34). In contrast, the regional PDFV progressively decreased toward the apex in patients with diastolic dysfunction (PDFV at the mitral tips: 0.82 m/s, PDFV at 3 cm: 0.63 m/s; P =.0004). Only 77% of the initial velocity was maintained at 3 cm away from the mitral tips in patients with diastolic dysfunction, whereas almost 100% of the initial velocity was preserved in patients with normal diastolic function (P <.001). These findings suggest that the assessment of the intraventricular decrease in mitral PDFV may be used as a reliable marker of diastolic dysfunction in patients with atrial fibrillation.

Compliant vs non-compliant balloons. A prospective randomized study.

In this prospective randomized trial we explored the possibility of different procedural outcomes with regard to compliant (polyolefin copolymer (POC)), and non-compliant (polyethylene terapthelate (PET)) balloon materials commonly used during percutaneous transluminal coronary angioplasty (PTCA). For this purpose, 51 female and 149 male (total 200) patients were randomized to 100 compliant and 100 non-compliant balloons. Only single lesions were included in the study and patients who had PTCA for more than one lesion in different segments at different sessions were each entered separately (there were actually 49 female and 143 male patients). PTCA procedures were performed in conjunction with quantitative coronary angiographic techniques and the films were reviewed by two investigators in a blinded fashion. Statistical analysis for various procedural end-points were performed by non-paired Student t test with statistical significance being p < 0.05. There were no differences in demographic and clinical characteristics between groups. Lesion characteristics of both groups were exactly matching for vessel size, balloon size, balloon vessel ratio, minimal luminal diameter and percent stenosis of the index lesion. Similarly, minimal residual diameter, percent residual stenosis, net gain, densitometric net area gain, and maximum pressure (2.2 +/- 5 mm vs 2.1 +/- 0.6 mm, 18 +/- 17% vs 23 +/- 15%, 0.8 +/- 0.5 mm vs 0.8 +/- 0.6 mm, 48 +/- 25% vs 48 +/- 26%, 7.3 +/- 2 atm. vs 6.8 +/- 3 atm., respectively) values were not statistically different between compliant and non-compliant balloon groups. Major in-hospital complications, dissections caused by the study balloon (mostly type A and B), crossover and bail-out procedures (5 vs 3, 34 vs 32, 4 vs 3, 13 vs 14, respectively) were similar for both compliant and non-compliant balloon groups. Study balloon success rate (defined as < 50% residual stenosis or > 20% net gain in the absence of major in-hospital complications, crossovers and bail-outs) and overall procedural success rate (80% vs 74%, 90% vs 85%) were not statistically different for compliant and non-compliant balloons. In conclusion, we did not observe any statistically significant difference between compliant and non-compliant balloons in terms of immediate procedural results.

Directional coronary atherectomy versus coronary angioplasty in vessels larger than 3 mm in diameter.

It has been proposed that directional coronary atherectomy (DCA) should be an intervention of choice in larger vessels as one can achieve a greater minimal luminal diameter with DCA than with percutaneous transluminal coronary angioplasty (PTCA). This in turn should translate into a higher success rate and may even reduce the restenosis rate. The aim of this study was to compare DCA versus PTCA in vessels > 3 mm in diameter. One hundred fifty consecutive patients who met the inclusion criteria and had DCA were compared to 150 similarly selected PTCA patients. PTCA patients were selected from the era immediately preceding the advent of DCA so that selections bias could be excluded. All patients with ostial lesions, restenosis, vessels < 3 mm in diameter, and vessels with more than two significant lesions were excluded. Distal segments and circumflex cases were excluded as they formed a small subsegment. Both groups were similar in terms of demographic, clinical and angiographic variables. Quantitative analysis showed that the initial net gain was significantly greater in the DCA group than in the PTCA group (2.36 +/- 0.8 mm vs. 1.78 +/- 0.7 mm; p < 0.05). Residual stenosis was 11% with DCA compared to 33% with PTCA (p < 0.05). Despite these improved anatomical results the procedural success rates were similar (91.5% vs 84%). Major in hospital complications (death, acute occlusion, MI, emergency CABG, re-do) were higher in the DCA group than in the PTCA group (12% vs 6%). Clinical follow-up on 276 patients (150 DCA vs 126 PTCA) showed a 6 month clinical restenosis rate of 18% vs 28%, respectively. The incidence of re-do in 24 hours for acute occlusion was 6% for DCA and 1% for PTCA. In large-sized vessels DCA results in a lower restenosis rate. However, despite a lower incidence of residual stenosis, the complication rate tends to be higher with DCA (p < 0.05).

Infusion versus bolus injection of Tc-99m tetrofosmin in the identification of viable myocardium.

In this report, a patient with 100% RCA stenosis and prominent collaterals, in which TI-201 rest/redistribution and Tc-99m tetrofosmin infusion imaging findings were compatible with viable myocardium in contrast to Tc-99m tetrofosmin bolus imaging is presented. Viability was confirmed with improvement of wall motion and perfusion 3 months after revascularization. Infusion of Tc-99m tetrofosmin rather than a bolus injection may be a more reliable technique in the identification of severely ischemic but viable myocardium.

Comparison of Angiographic and Clinical Outcome After Cutting Balloon and Conventional Balloon Angioplasty in Vessels Smaller than 3 mm in Diameter: A Randomized Trial.

OBJECTIVES: The purpose of the study was to evaluate and compare the immediate and six month follow-up angiographic and clinical outcome of cutting balloon angioplasty and conventional balloon angioplasty in small vessels (less than 3 mm in diameter). METHODS AND RESULTS: Between August 1995 and August 1996 a total of 71 eligible symptomatic patients with angiographically proven significant lesions in their coronary arteries smaller than 3 mm and requiring revascularization, were randomized to receive treatment by either cutting balloon angioplasty (CB) or conventional balloon angioplasty (BA). ÒStand-aloneÓ CB was performed on 51 lesions in 36 patients and BA on 47 lesions in 35 patients. Basic angiographic and clinical characteristics were similar in both groups. The overall procedural success rates for CB and BA groups were 92% and 97%, respectively. The immediate post-procedural minimal luminal diameter, residual stenosis and acute gain were similar in the CB and BA cohorts (1.93 +/- 0.36 mm, 24 +/- 12%, 1.18 +/- 0.45 mm vs. 2.01 +/- 0.34 mm, 22 +/- 9%, 1.26 +/- 0.35 mm, respectively). Total dissection rate and C-F dissections were fewer in the CB group (37%, 6% vs. 51%, 19%, respectively, p < 0.05). Six month follow-up angiographic restenosis rate was lower in the CB group (27% vs. 47%, p < 0.05). We also detected a significant difference of total number of all events at nine month clinical follow up (28% vs. 51%, p < 0.05). CONCLUSION: CB angioplasty can be performed with a comparable success rate to conventional BA in small vessels. Fewer bail-out procedures are needed as CB causes fewer and less severe dissections. There is also a significant reduction in six month restenosis rate. We suggest that CB might be a better option for revascularizing vessels smaller than 3 mm in diameter which are inherently more prone to immediate complications and late restenosis with BA.