A Novel-Modified Provisional Bifurcation Stenting Technique: Jailed Semi-Inflated Balloon Technique.

OBJECTIVE: We proposed a new technique for the treatment of coronary bifurcation lesions, called jailed semi-inflated balloon technique (JSBT). BACKGROUND: Currently, provisional approach is recommended to treat most of coronary bifurcation lesions. However, it is associated with the risk of side branch (SB) occlusion after main vessel (MV) stenting due to plaque or carina shift into the SB. The SB occlusion may cause peri-procedural myonecrosis or hemodynamic compromise. Therefore, strategies are needed to reduce the SB occlusion during provisional approach. METHODS: Between September 2014 and April 2015, we selected 137 patients (104 male, 33 female; mean age 63.6 ± 11.7 years) with 148 distinct coronary bifurcation lesions underwent percutaneous coronary intervention using JSBT. All patients were followed with hospital visits or telephone contact up to 1 month. RESULTS: The majority of the patients had acute coronary syndrome (64.2%) and Medina 1.1.1. bifurcation lesions (62.8%). The lesion localization was distal left main (LM) coronary artery in 28 patients. After the MV stenting, thrombolysis in myocardial infarction (TIMI) 3 flow was established in 100% of both MV and SB. There was no SB occlusion in any patient. There was no major adverse cardiac event during in-hospital stay and 1 month follow-up. CONCLUSIONS: The JSBT technique can be successfully performed in both LM and non-LM bifurcation lesion. This technique provides high rate of procedural success, excellent SB protection during MV stenting and excellent immediate clinical outcome.

An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among non-valvular atrial fibrillation patients in Turkey- AFTER-2 study design.

OBJECTIVES: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. STUDY DESIGN: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). RESULTS: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. CONCLUSION: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

Increased echocardiographic epicardial fat thickness is related to impaired diurnal blood pressure profiles.

OBJECTIVE: Epicardial fat has been proposed as a new cardiometabolic risk factor. Although epicardial fat thickness (EFT) is associated with hypertension, the relationship between diurnal blood pressure profiles and EFT is still unknown. The purpose of this study is to investigate the association between the echocardiographic EFT and diurnal blood pressure profiles in hypertensive patients. METHODS: After the ambulatory blood pressures of 123 patients were monitored, they were divided into three groups according to the clinical diagnoses: 41 patients (33.3%) were in the normotensive group, 40 patients (32.5%) were in the dipper hypertensive group and 42 patients (34.1%) were in the non-dipper hypertensive group. All participants underwent transthoracic echocardiography and ambulatory blood pressure monitoring to measure the EFT and blood pressure responses. RESULTS: The mean EFT measurements of the dipper group were significantly higher than the normotensive group (6.5 ± 0.6 vs 5.8 ± 0.6; p < 0.0001). On the other hand, the mean EFTs of the non-dipper group were also significantly higher than the dipper group (7.4 ± 0.7 vs 6.5 ± 0.6, p < 0.0001). An EFT of ≥ 7 mm predicted the non-dipper profile in hypertensive patients with 74% sensitivity and 71% specificity (receiving operator characteristic area under the curve: 0.826, 95% CI 0.738-0.913; p < 0.0001). EFT was associated with both dipper (OR 8.9, 95% CI 3.03-26.3; p < 0.0001) and non-dipper blood pressure profiles (OR 12.3, 95% CI 1.75-86.31; p < 0.0001), and this relationship was also independent from all the risk factors. CONCLUSION: Echocardiographic EFT assessment is independently associated with impaired diurnal blood pressure profiles in the hypertensive individuals. Thus, the echocardiographic assessment of the EFT may be helpful in cardiometabolic risk stratification and therapeutic interventions.

Impact of body mass index on left ventricular diastolic dysfunction.

BACKGROUND: The prevalence of obesity is increasing in the developed and developing world. It is an independent risk factor for heart failure. Left ventricular (LV) diastolic dysfunction has been demonstrated to be a strong predictor of heart failure. In the present study we aimed to assess the impact of body weight on LV diastolic function. METHODS: The study was conducted on 2,228 participants (1,424 women, 804 men with a mean age of 49). Traditional and tissue Doppler echocardiographic examination were performed in all of the participants. The demographic and echocardiographic data were compared. Multivariate logistic regression analysis was used to assess the independent predictors of association of LV diastolic function. The study sample was divided into four groups: group 1 (body mass index [BMI] < 25.0 kg/m(2) ), group 2 (BMI 25.0-29.9 kg/m(2)), group 3 (BMI ≥ 30-39.9 kg/m(2)), and group 4 (BMI ≥ 40 kg/m(2)). RESULTS: Septal E was significantly lower in groups 2 and 3 compared to group 1 (P = 0.003). Septal A and septal A' were significantly higher whereas septal E' and lateral E' were significantly lower in the groups 2, 3, and 4 compared to the normal weight group (P < 0.001). Lateral A', deceleration time, and ejection time were significantly higher in obese when compared to the normal weight (P = 0.025, P < 0.001, and P = 0.009, respectively). The E/E' ratio was significantly higher in groups 2, 3, and 4 compared to the group 1 (P < 0.001). Logistic regression analysis revealed that age, BMI (OR = 1.060 [95% CI = 1.040 and 1.080]; P < 0.001), hypertension, and diabetes mellitus were independent predictors of LV diastolic dysfunction. CONCLUSION: BMI is an independent predictor of LV diastolic dysfunction along with age, hypertension, and diabetes mellitus.

Carotid artery stiffness in patients with neurally mediated syncope.

OBJECTIVES: Neurally mediated syncope is defined as a transient loss of blood flow to the brain, resulting in vasodilatation, bradycardia, or both. The pathophysiologic mechanisms of neurally mediated syncope are not clear. In this study, we investigated carotid artery elasticity parameters in patients with neurally mediated syncope. METHODS: The study was conducted on 41 patients who were examined by the tilt table test. Group 1 constituted of 21 patients who had a positive response to the tilt table test. Clinical and hemodynamic parameters were compared with patients in a negative tilt table test group (group 2). The systolic and diastolic diameters of the carotid arteries, carotid distensibility, carotid strain, carotid stiffness index, and carotid elastic modulus of the left carotid arteries were calculated by a high-resolution ultrasound device. RESULTS: No differences in hemodynamic variables or clinical parameters were detected between the groups. Carotid distensibility (mean ± SD, 1.6 ± 0.6 versus 2.2 ± 0.8 cm(2) × dyne(-1) × 10(-6); P = .044) and strain (6.8% ± 1.7% versus 8.2% ± 1.9%; P = .026) were lower in group 1 than in group 2. The carotid elastic modulus (0.88 ± 0.33 versus 0.74 ± 0.25 cm(2) × dyne(-1) × 10(-6); P = .002) and stiffness index (6.7 ± 0.4 versus 6.2 ± 0.5; P = .038) were higher in group 1. CONCLUSIONS: In this study, we concluded that elastic properties of the carotid artery are impaired in patients with neurally mediated syncope. This finding suggests that impaired carotid arterial elasticity may be a factor in the pathophysiologic mechanisms of neurally mediated syncope.

Mean platelet volume in predicting short- and long-term morbidity and mortality in patients with or without ST-segment elevation myocardial infarction.

Mean platelet volume (MPV) is a marker of platelet activation. An increased MPV is associated with acute myocardial infarction (AMI) and long-term mortality. The aim of this study was to compare MPV in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). Also, we investigated the value of MPV on in-hospital mortality and long-term prognosis of patients with STEMI and NSTEMI. We studied 429 patients with AMI (70.4% male, 61.9 ± 12.4 years; 279 patients with STEMI, 150 patients with NSTEMI). MPV and platelet count were similar in both groups. Elevated MPV increased the risk of death by 3.1-fold (p < 0.001) in STEMI group during the hospitalization. However, increased MPV was not associated with in-hospital mortality in NSTEMI group. The area under the receiver operating characteristic curve of MPV was 0.868 (95% CI, 0.830-0.907) for predicting two-year mortality. A cut-off point of 11.1 fL showed a sensitivity of 81% and a specifity of 77% for prediction of two-year mortality. Kaplan-Meier survival curve showed two-year mortality rate of 12.5% in patients with MPV >11.1 fL versus 9.9% in patients with MPV <11.1 fL (p < 0.001). Cox regression analysis showed MPV to be an independent predictor of two-year mortality (Hazard ratio 1.7; 95% CI 1.5-1.9; p < 0.001). An increased MPV is an independent predictor of in-hospital mortality in patients with STEMI. However, elevated levels of MPV did not predict in hospital mortality in NSTEMI group. The increase in MPV values was independently correlated with two-year mortality in all study patients.

Association of neutrophil-lymphocyte ratio with the presence and severity of rheumatic mitral valve stenosis.

The aim of the study is to investigate the association between the severity of rheumatic mitral valvular disease (RMVD) and the neutrophil-lymphocyte ratio (NLR). A total of 227 patients were enrolled in the study and divided into 3 groups. Patients in group 1 had rheumatic mitral stenosis (RMS), those in group 2 had RMVD without stenosis, and those in group 3 served as the control group. Group 1 was further divided into 2 groups, severe mitral stenosis (MS) and mild to moderate MS. The NLR was significantly higher in patients with severe MS when compared to those with mild to moderate MS (P = .002) while lymphocyte count was lower (P = .034). Using a cutoff level of 2.56, the NLR predicted severe RMS with a sensitivity of 75% and specificity of 74%. In conclusion, as an inexpensive, simple, and accessible marker of inflammation, the NLR may be useful in predicting the presence and severity of MS in patients with RMVD.

Association between neutrophil to lymphocyte ratio and severity of coronary artery disease.

The aim of this study is to investigate the association between neutrophil to lymphocyte ratio (NLR) and severity of coronary atherosclerosis. A total of 172 patients undergoing coronary angiography were included in the study. Control group consisted of patients with normal coronary arteries. Patients with coronary stenosis were divided into 2 groups by use of Gensini scores. The NLR was higher in severe atherosclerosis group compared with mild atherosclerosis and control groups (P < .001). In correlation analysis, NLR showed significant correlation with Gensini score. A cutoff value of 2.5 for NLR predicted severe atherosclerosis with a sensitivity and specificity of 62% and 69%, respectively. After multivariate analysis, high levels of NLR were independent predictors of severe atherosclerosis together with glucose and high-density lipoprotein. Our study suggests that the NLR is a predictor of severe atherosclerosis that may be useful for cardiac risk stratification in patients with coronary artery disease.

The relationship between coenzyme Q10 and severity of coronary artery disease.

AIM: To evaluate the relationship between the levels of plasma coenzyme Q10 (CoQ10), a known antioxidant, and severity of the coronary atherosclerosis (AS) measured by Gensini score. METHODS: Patients with coronary artery disease (CAD) were enrolled to the study between 2010 and 2011 in cardiology outpatient clinics. They were admitted for diagnostic coronary angiography or angioplasty for typical indications. The Gensini scoring system was used to calculate CAD severity. Serum CoQ10, total cholesterol (TC), HDL cholesterol, LDL cholesterol, and triglyceride levels were assessed. RESULTS: One hundred thirteen subjects (83 CAD, 30 controls) were included. The patients with CAD were separated into three groups according to Gensini score. The serum levels of CoQ10, CoQ10/ TC, CoQ10/LDL-C, CoQ10/TG rates in the subjects of mild and severe AS groups were significantly lower than the control group ( p less than 0.016 for all control vs. AS group comparisons). There were no significant differences in serum levels of CoQ10 and CoQ10/ TC, CoQ10/LDL-C, CoQ10/TG rates between the mild and severe AS groups. CONCLUSION: This study revealed that although the serum CoQ10 levels were lower in stable CAD, there was no relationship between the severity of CAD and serum CoQ10 levels in patients with stable angina pectoris.

Myocardial infarction secondary to unintentional ingestion of hydrogen peroxide.

Ingestion of acid-containing household products, either accidentally or as a suicide attempt, is a common form of intoxication. A clear and odorless liquid, hydrogen peroxide is an oxidizing agent found in most households and many industrial environments. Cardiovascular manifestations of hydrogen peroxide ingestion are extremely rare. Here we report a 60 year-old woman with acute inferolateral myocardial infarction (MI) after hydrogen peroxide ingestion, who had no history of coronary artery disease. Physicians dealing with hydrogen peroxide ingestion in the emergency department should be aware of the probability of MI and obtain an electrocardiogram, even if the patient has no cardiac complaint.

Left ventricle hydatid cyst mimicking acute coronary syndrome.

Cardiac echinococcosis rarely mimics acute coronary syndrome. The diagnosis of cardiac hydatid cyst might be difficult on account of varying clinical presentations and nonspesific symptoms. A 75-year-old female was admitted to our hospital with typical chest pain. The patient had no history of previous cardiac symptoms or any illness leading to heart disease. Her ECG revealed ischemic changes. However, her coronary angiography revealed noncritical plaques in the left anterior descending artery. The diagnosis of cardiac echinococcosis was identified using echocardiography, computed tomography and magnetic resonance imaging. The patient was referred to cardiac surgery for resection of the cyst; however, she refused surgery. Albendezol 800 mg/day was prescribed.

Platelet count and mean platelet volume in patients with in-hospital deep venous thrombosis.

AIM: To investigate the relationship between mean platelet volume (MPV) and in-hospital deep venous thrombosis (DVT). MATERIAL AND METHODS: 147 patients with the diagnosis of DVT and 149 control participants were included in the study. For all participants, clinical risk factors, smoking status, and other demographic data were recorded from hospital registries. The data of patients with DVT were compared with the control participants. RESULTS: Mean MPV was significantly higher in patients with DVT than the control group (8.91 ± 1.86 vs 7.86 ± 0.9; P < .001). Body mass index, smoking frequency, hematocrit, and platelet count were significantly correlated with MPV. Independent predictors of in-hospital DVT were MPV (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.2-1.87; P ≤ .001), body mass index (OR = 1.17; 95% CI = 1.04-1.34; P = .012), and smoking (OR = 1.83; 95% CI = 1.09-3.08; P = .023). CONCLUSION: Mean platelet volume was significantly higher in patients with DVT, and it is an independent predictor of in-hospital DVT.

The relationship between serum levels of Zn and Cu and severity of coronary atherosclerosis.

The essential trace elements play important roles in the maintainance of the normal structure and physiology of cells. Several research groups have demonstrated that they also play important roles in states of cardiovascular diseases. Our aim is to investigate whether there is a relationship between trace elements (Zn and Cu) and the degree of atherosclerosis. The sample consisted of 67 patients with coronary artery disease and 26 clinically healthy individuals. Ninety-three subjects were separated into four groups according to their Gensini scores, the number of diseased vessels, the presence of acute coronary syndrome, and ejection fraction. Each group was divided into three subgroups, and serum zinc and copper levels were measured for each individual. The serum levels of zinc and copper were found to be significantly lower in patients with atherosclerosis than in the control group, but there were no significant differences in the serum levels of Cu and Zn between severe atherosclerosis and mild atherosclerosis. In Spearman's rank correlation, the zinc and copper levels were correlated with the Gensini score and the number of diseased vessels. The present study revealed a relationship between the serum levels of zinc and copper and atherosclerosis, but not between these levels and the severity of the disease.

Comparison of left ventricular functional parameters obtained from three different commercial automated software cardiac quantification program packages and their intraobserver reproducibility.

OBJECTIVE: ECG-gated myocardial perfusion scintigraphy (MPS) can be used to determine several cardiac functional parameters (e.g., left ventricular ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV)). In this study, we aimed to compare these cardiac functional parameters calculated by the following cardiac quantification programs: Emory Cardiac Toolbox (ECTb), Quantitative Gated SPECT (QGS), and Myometrix. We also evaluated reproducibility of the cardiac programs. METHODS: Fifty-seven patients (27 male, 30 female) at Elazig Research and Training Hospital from 2008 to 2009 were included in this study. In all patients, (99m)Tc-MIBI ECG-Gated (8-bin frame mode) myocardial perfusion scintigraphies were performed. By using 3 different cardiac quantification programs (ECTb, QGS, and Myometrix); LVEF, EDV, and ESV were calculated. The same raw data of MPS images were reprocessed at different time periods, and these 3 parameters were recalculated. LVEF, EDV, and ESV yielded by 3 different programs were compared for interprogram variability assessment, and parameters calculated at two different time periods were compared to evaluate intraprogram reproducibility. RESULTS: There were statistically significant differences between ECTb, QGS, and Myometrix programs for LVEF, EDV, and ESV (p < 0.001). There was also a statistically significant correlation between LVEF and EDV (p < 0.001, r = 0.546; p < 0.001, r = 0.45, respectively), but no statistically significant correlation was present between the ESV values (p > 0.05, r = 0.09). Statistically significant differences were not found between the values of LVEF, EDV, and ESV obtained from the first and second reconstruction analysis of 3 cardiac quantification programs. DISCUSSION: Different MPS cardiac software programs give variable (but correlated) LVEF and left ventricular volumetric measures. Those obtained from different cardiac softwares cannot be used interchangeably. Our findings have shown that ECTb, QGS, and Myometrix programs are reproducible, with respect to LVEF, EDV, and ESV.