A Very Rare Case of Co-Existence of Cor Triatriatum Sinister and Left Pulmonary Vein Atresia.

Cor triatriatum sinister (CTS) is a rare congenital abnormality. Clinical presentation of patients with CTS mainly depends on the anatomic features of membrane and may vary from mild or moderate symptoms mimicking mitral stenosis to more severe and complicated cardioembolic stroke or a new onset heart failure. We herein have reported on a young male who presented with the signs and symptoms of mitral stenosis and was diagnosed as CTS with gradient on the orifice of the membrane after transthrocacic echocardiography. Computerized tomographic angiography revealed that the patient had unilateral, left sided pulmonary arterial hypoplasia and pulmonary vein atresia, with only the right pulmonary veins draining into the left atrial chamber. Further cardiac imaging by either computed tomography or magnetic resonance imaging is necessary in order to seek accompanying cardiac and vascular abnormalities. Patients with CTS have improved short and long term survival rates if CTS and accompanying abnormalities are surgically treated before the disease is complicated with heart failure, pulmonary hypertension, stroke and etc.

The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation.

OBJECTIVE: To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE). MATERIALS AND METHODS: The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study. RESULTS: A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF. CONCLUSION: A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.

Comparative effects of nebivolol and metoprolol on red cell distribution width and neutrophil/lymphocyte ratio in patients with newly diagnosed essential hypertension.

High level of circulating red cell distribution width (RDW) and neutrophil/lymphocyte (N/L) ratio may reflect ongoing vascular inflammation and play an important role in pathophysiology of hypertension. We evaluate the effects of nebivolol and metoprolol on the RDW and N/L in new essential hypertensive patients. After baseline assessment, 72 patients were randomly allocated to 5 mg/d of nebivolol (n = 37, 20 men) or 100 mg/d of metoprolol (n = 35, 18 men) and treated for 6 months. Blood pressure (BP), heart rate (HR), RDW, and N/L were measured before and after treatment. BP significantly decreased with both drugs (P < 0.001). Analog reduction was observed for resting HRs (P < 0.001), but metoprolol caused greater HR fall as compared with nebivolol (P < 0.001). After 6 months of treatment, nebivolol significantly lowered not only RDW but also the total white blood cell and N/L (P < 0.001, P = 0.023, P = 0.017, respectively). No changes were observed in metoprolol group. Percent decrease in RDW was found to be significantly higher in nebivolol than in the metoprolol group (P = 0.001) and remained also after correction for confounders (P = 0.012). Nebivolol improved RDW and N/L to a greater extent than metoprolol in patients with hypertension. These favorable effects may participate, together with the BP reduction, at the favorable properties of the drug in hypertension.

Enlargement of the aorta: An occupational disease?

BACKGROUND: Aortic dilation may critically precede progression to thoracic aortic aneurysm (TAA). Prolonged or repetitive isometric-type heavier strenuous activities resulting from the nature of some professions may be an important causative factor for TAA. METHOD: The echocardiographic measurement data of middle-age subjects who were isometric-type daily strenuous activity trainers or ordinary activity trainers were retrospectively analyzed. Clinical features and echocardiographic parameters of the left ventricle and left atrium (LA), aortic root (AR) and ascending aorta (AA) were compared between the groups. RESULTS: AR (35.6±3.0 mm versus 33.5±1.9 mm), AA (36.8±3.0 mm versus 34.4±1.9 mm) and LA (37.4±2.2 mm versus 36.2±2.2 mm) diameters were significantly enlarged in the strenuous activity trainer group versus the ordinary activity group. Diastolic blood pressure was significantly lower (73.8±5.9 mmHg versus 78.3±6.0 mmHg) in this group. AR diameter was correlated with height (ß=0.460; P=0.004) and LA diameter (ß=0.280; P=0.008) while AA diameter was correlated with type of profession (ß=0.309; P=0.003), left ventricular systolic diameter (ß=0.500; P=0.001) and LA diameter (ß=0.272; P=0.005) in regression analysis. CONCLUSION: Aortic dilation and, subsequently, TAA may be an occupational disease due to nature of some professions (eg, the military, security, weight lifters, athletes, heavy workers, etc). Echocardiography is a convenient method of imaging that could be easily applied either during preparticipation screening or during periodical examination of these subjects. Earlier detection of TAA and limitation of such strenuous activities in these individuals may be initial lifesaving measures for the prevention of future cases of aortic aneurysm and dissection.

Classic mitral valve prolapse causes enlargement in left ventricle even in the absence of significant mitral regurgitation.

AIM: The aim of this study was to evaluate whether left ventricular size was increased in patients with classic bileaflet mitral valve prolapse (MVP) in the absence of significant mitral regurgitation (MR). METHOD: Patients with classic bileaflet MVP were included as the case group. Two different control groups were established. The first control group was composed of the patients with mild MR caused by the reasons except MVP. The second control group consisted of healthy individuals whose echocardiograms were normal. The patients with moderate or severe MR and having abnormality in the other valves were excluded. RESULTS: There were 20 patients in each group. Systolic and diastolic diameters and volumes of left ventricle (LV) in the MVP group were significantly higher than those in the control groups. In 10 of the patients in the MVP group, LV internal diastolic diameter (LVIDD) values were measured as ≥5.7 cm, whereas increased LVIDD value was detected in only one patient in the other two control groups. There was a significant difference in terms of the presence of increased LVIDD values between the MVP group and the control groups. Despite this enlargement in the LV dimension, the LV ejection fractions were found similar in all groups. Furthermore, it was found that the lengths of both anterior and posterior mitral leaflets in MVP group were significantly higher than those in the control groups. CONCLUSION: The LV diameters and volumes of patients with classic bileaflet MVP were found to be increased even in the absence of significant MR. These results need to be supported by large-scale clinical studies.

Cardiovascular risk scores for coronary atherosclerosis.

OBJECTIVE: The objective of this study was to compare frequently used cardiovascular risk scores in predicting the presence of coronary artery disease (CAD) and 3-vessel disease. METHODS AND RESULTS: In 350 consecutive patients (218 men and 132 women) who underwent coronary angiography, the cardiovascular risk level was determined using the Framingham Risk Score (FRS), the Modified Framingham Risk Score (MFRS), the Prospective Cardiovascular Münster (PROCAM) score, and the Systematic Coronary Risk Evaluation (SCORE). The area under the curve for receiver operating characteristic curves showed that FRS had more predictive value than the other scores for CAD (area under curve, 0.76, P < or = 0.001), but all scores had good specificity and positive predictive value. For 3-vessel disease, the FRS had better predictive value than the other scores (area under curve, 0.74, P < or = 0.001), but all scores had good specificity and negative predictive value. CONCLUSION: The risk scores (FRS, MFRS, PROCAM, and SCORE) may predict the presence and severity of coronary atherosclerosis.The FRS had better predictive value than the other scores.

Alternative method for accessing the target coronary artery in patients with difficult coronary anatomy: exchanging the diagnostic catheter with a guiding catheter.

We report a method of the placement of the guiding catheter in two cases in which the diagnostic catheter could be easily engaged to the target coronary arteries but not a guiding catheter, due to a distorted aortic sinus and an osteal subtotal occlusion, respectively. After engaging to the target coronary artery with a diagnostic catheter, a coronary guidewire was advanced through the diagnostic catheter, and exchanged with a guiding catheter over the guidewires. The procedures were completed with success.

Fenestrated cor triatriatum sinistrum: a case report.

We present a 20-year-old male patient with cor triatriatum sinistrum with fenestrations and long-standing dyspnea on exertion, fatigue, and palpitation. An apical early to mid-systolic murmur of grade I-II/VI was heard on cardiac auscultation. Electrocardiography showed sinus rhythm and an incomplete right bundle branch block. Transthoracic echocardiography showed a membrane dividing the left atrium into two compartments. Transesophageal echocardiography showed a membrane with fenestrations originating from the left upper pulmonary vein, extending to the interatrial septum, and dividing the left atrium into two compartments as proximal and distal. Cardiac MR imaging for further detailed anatomical assessment demonstrated similar findings without additional anomaly. Medical follow-up was conducted due to no pressure gradient across the membrane.

Association of plasma B-type natriuretic peptide levels with shunt size in young adults with atrial septal defect.

OBJECTIVE: This study was designed to investigate the validity of brain natriuretic peptide (BNP) levels for the estimation of the shunt size in young adults with atrial septal defect (ASD), and to determine the relationship between BNP levels and echocardiographic parameters of right heart chambers. METHODS: Fifty-six patients with ASD (mean age 22.9 ± 2.0 years) were studied. The control group consisted of 31 age-gender matched healthy volunteers (mean age 22.7 ± 1.9 years). Coventional echocardiography, tissue Doppler imaging (TDI) and plasma BNP level measurement was performed in all participants. The ratio of pulmonary to systemic blood flow (Qp/Qs) was measured noninvasively using transthoracic echocardiography. RESULTS: Plasma BNP levels were significantly higher in ASD patients than in controls (42.9 ± 29.4 vs. 8.3 ± 2.6 pg/mL, P < 0.05). Pulmonary artery pressure (PAP) (P = 0.0001), right atrium (RA) volume (P = 0.0001), and right ventricular end-diastolic volume (RVEDV) (P = 0.0001) values were higher in ASD patients. There was a powerful correlation between plasma BNP levels and Qp/Qs ratio (r = 0.71, P < 0.0001). The plasma BNP levels significantly correlated with PAP (r = 0.61, P < 0.0001), RA volume (r = 0.54, P < 0.0001), RVEDV (r = 0.55, P < 0.0001), and right ventricular myocardial performance index (r = 0.50, P < 0.0001). CONCLUSION: This study shows that there is a significant correlation between right heart echocardiographic parameters and concentrations of BNP in the plasma of young adults with ASD. BNP levels may provide a supplemental data to predict of shunt size in these patients.

Effect of position changes on myocardial velocity in healthy subjects evaluated by tissue Doppler echocardiography.

OBJECTIVES: This study designed to assess the effect of different positions of head of the bed on myocardial velocity by tissue Doppler echocardiography in healthy subjects. METHODS: Thirty-nine healthy subjects (32 males/7 females, mean age 24.7 ± 4.9 years) were studied. Tissue Doppler imaging (TDI) was performed and velocities were recorded during systole (Sm) and early (Em) and late (Am) diastole at the tricuspid annulus, septum, and mitral annulus in the four-chamber view. Measurements were performed from different positions of left lateral decubitus (0°, 30°, and 60°). Repeated-measures general linear models were used to assess the change in myocardial velocities. RESULTS: No significant difference between myocardial velocities was found at the mitral anulus and septal TDI recordings in the different angles of left lateral decubitus positions (P > 0.05). However, there were statistically significant difference among tricuspid anulus myocardial tissue velocities in these positions (P < 0.05). CONCLUSIONS: Tricuspid anulus myocardial tissue velocities may be significantly influenced by changing of position in healthy subjects. Effect of position changes should be considered in the assessment of these velocities.

CA-125 level is associated with right ventricular echocardiographic parameters in patients with COPD.

OBJECTIVE: A few studies have shown that elevated CA-125 levels are associated with chronic obstructive pulmonary disease (COPD). However, there are no data concerning the associaton between serum CA-125 levels and right ventricular (RV) function in COPD patients. This study aimed to evaluate the relationship between CA-125 level and RV echocardiographic parameters in COPD patients. METHODS: Fifty-two patients with COPD (39 male/13 female, mean age 68.9 ± 5.7 years) were studied. The control group consisted of 30 age-sex matched healthy volunteers (23 male/7 female, mean age 64.2 ± 6.3 years). Patients were divided into two subgroups: patients without pulmonary hypertension (group I, n = 25) and with pulmonary hypertension (group II, n = 27). Conventional echocardiographic parameters, tissue Doppler imaging (TDI) and CA-125 level measurements were performed in all subjects. RESULTS: Patients in group II had significantly higher CA-125 levels than those in group I and controls (P < 0.01). CA-125 levels in group I were also higher than control group (P < 0.05). CA-125 levels were correlated with left ventricle E/A ratio, systolic pulmonary artery pressure (sPAP), RV myocardial performance index, and RV fractional area change (r = 0.37, 0.56, 0.34, and -0.42, respectively, all with P < 0.05). There was an independent correlation between CA-125 levels and sPAP values (ß = 0.76, P < 0.001). CONCLUSIONS: Our results show an independent correlation between CA-125 levels and systolic pulmonary artery pressure in COPD patients. The clinical utility of these results at this point in time is unknown and deserves future research.

Advanced Age, Female Gender and Delay in Pacemaker Implantation May Cause TdP in Patients With Complete Atrioventricular Block.

AIM: We aimed to report the clinical features related to torsades de pointes (TdP) in patients with complete AV block (CAVB). METHODS: Patients with CAVB who were admitted to our instituition between January 2007 and January 2010 were retrospectively evaluated in terms of the occurence of TdP. The clinical features were compared in patients with and without TdP using the software of SPSS. RESULTS: Sixty-four patients were determined to have CAVB. Three of them had documented episodes of TdP. All three patients experiencing TdP were females, whereas 48% of the patients with CAVB were females. The mean age of patients with TdP was significantly greater than the mean age of the other patients (85 ±3 vs. 78±7.6, respectively; p<0.05). In our archives, bradycardia exposure time could be determined in only 49 patients without TdP. Among them, just 10 patients had been exposed to bradycardia over 48 hours, whereas all of the 3 patients with TdP had been exposed to bradycardia over 48 hours (p<0.05). Additionally, in two patients with TdP, we demonstrated that QT and QTc prolongation increases as the duration of bradycardia is extended. Furthermore, all patients with TdP had notched T waves in the ECG on the occurrence day of TdP, whereas they did not have any notched T wave in their ECG on the admission day. CONCLUSION: Among the patients with CAVB, elderly females are more susceptible to development of TdP. Delay in institution of physiological heart rate leads to further QT prolongation and thereby to TdP. Besides QT prolongation, the finding of T wave notching on ECG may also have a predictive value for TdP.

[Prominent mitral L wave in a patient with partial pericardiectomy: a possible new etiology]. / Mitral L dalgasinin olasi yeni bir nedeni: Kismi perikardiyektomili bir hastada belirgin mitral L dalgasi

The middiastolic flow of mitral L wave may result from pathologies that impair the diastolic function of the heart. Echocardiographic examination of a 48-year-old female patient with a three-year history of partial pericardiectomy showed mild left ventricular hypertrophy, mild mitral regurgitation, and mitral annular calcification. During pulse-Doppler examination, a prominent forward transmitral flow (mitral L wave) was noted. The patient developed supraventricular tachycardia attacks on simultaneous electrocardiographic monitoring, during which the mitral L wave disappeared, but E and A waves sustained. Variations in the velocities of the forward transmitral flow were less than 25% during deep inspiration. Tissue Doppler imaging showed equal velocities (0.06 m/sec) of the E' and A' waves recorded at the lateral mitral annulus.

[Adherence to statin therapy and LDL cholesterol goal attainment in type 2 diabetics and secondary prevention patients: the role of education and knowledge]. / Tip 2 diyabetiklerde ve ikincil koruma hastalarinda statin kullanimina uyum ve LDL-kolesterol hedefine ulasma düzeyleri: Egitim ve bilgi düzeyinin rolü

OBJECTIVES: Lipid levels of most patients receiving antilipidemic therapy are not under control as proposed by the guidelines. We evaluated adherence to statin therapy and LDL cholesterol goal attainment in type 2 diabetic and secondary prevention patients. STUDY DESIGN: A total of 194 patients (131 men, 63 women; mean age 57 ± 11 years) who had been on statin therapy for at least a year for a target LDL cholesterol level of <100 mg/dl were administered a two-part questionnaire. The first part inquired demographic and clinical characteristics, duration of hyperlipidemia, referral to a dietician, risk factors and, if present, the reasons for drug discontinuation. The second part consisted of 23 questions (total score 30) inquiring the knowledge levels of patients about hypercholesterolemia. RESULTS: There were 61 primary (31.4%, diabetics) and 133 secondary (68.6%) prevention patients. The mean LDL level was 122.6 ± 28.7 mg/dl. The incidence of attaining target LDL level was only 23.7% (n=46), being lower in diabetics compared to secondary prevention patients (6.6% vs. 31.6, p<0.0001). The mean knowledge score was 18.2 ± 5. When the threshold score was taken as 18 (median), attainment of the target LDL level was significantly higher in patients having a score of ≥ 18 (32%) compared to those with a lower score (14.9%). There were 77 patients (40%) who sought dietician counseling. Patients with a high school or higher education and those with dietician counseling had higher knowledge scores compared to those with a lower education level and without dietician counseling (p<0.0001). Intermittent drug discontinuation was seen in 109 patients (56.2%), the most common reason being decrease in cholesterol levels to normal (35%). CONCLUSION: Target LDL level was achieved in only about 24%. As the knowledge on hypercholesterolemia accrues, the success rate of LDL cholesterol goal attainment increases.

Urinary methylmalonic acid in patients with acute myocardial infarction.

OBJECTIVE: To investigate urinary methylmalonic acid (uMMA) levels and their relationship with markers of myocyte necrosis and inflammation in patients with acute myocardial infarction (AMI). SUBJECTS AND METHODS: The study participants consisted of 80 consecutive patients with AMI and 72 age- and sex-matched consecutive controls. Of the patients, 38 had ST segment elevation myocardial infarction (STEMI) and 42 had non-ST segment elevation. All patients with STEMI underwent fibrinolytic therapy. Routine laboratory tests included troponin-I, creatinine phosphokinase MB (CK-MB), high-sensitivity C-reactive protein (hs-CRP), vitamin B(12), folate, homocysteine and methylmalonic acid analyses. uMMA measurements were made by a spectrophotometric method. RESULTS: uMMA levels were significantly higher in patients with AMI than in controls (10.1 vs. 5.2 mmol/mol creatinine, p < 0.001) and higher in patients with anterior MI compared to those with non-anterior MI (18.9 vs. 8.7 mmol/mol creatinine, p < 0.001). In addition, uMMA levels were significantly higher in patients without successful reperfusion compared to those with successful reperfusion. In patients with STEMI, a strong positive association was found between urinary MMA and plasma hs-CRP levels (r = 0.81, p < 0.001), symptom duration (r = 0.91, p < 0.001) and wall motion score (r = 0.60, p = 0.006). More importantly, a strong positive association was observed between uMMA and the size of myocardial infarction in patients without successful reperfusion (for CK-MB r = 0.81, p = 0.013; for wall motion score r = 0.82, p = 0.012). CONCLUSION: uMMA levels were elevated in patients with AMI and, as such, may be a candidate biochemical indicator of larger infarct size and enhanced inflammation in patients with AMI.

The relationship between coronary calcification and the metabolic markers of osteopontin, fetuin-A, and visfatin.

OBJECTIVES: We investigated whether coronary calcification detected by multislice computed tomography (MSCT) was correlated with plasma osteopontin, serum fetuin-A, and visfatin levels. STUDY DESIGN: The study included 64 consecutive patients (51 males, 13 females; mean age 49.5+/-10.9 years; range 33 to 78 years) who underwent MSCT for suspected coronary artery disease. Coronary artery calcification (CAC) scores of the patients were calculated using the Agatston scoring method. Plasma osteopontin, serum fetuin-A, and visfatin levels were measured from fasting blood samples and correlations were sought with calcium scores. RESULTS: Coronary calcification was detected in 32 patients (50%). The mean CAC score was 146.5+/-333.7 Agatston units (AU), indicating an intermediate risk for coronary artery disease. In 10 patients (15.6%), the CAC score exceeded 400 AU. The mean fetuin-A, visfatin, and osteopontin levels were 25.6+/-6.4 ng/ml, 19.7+/-47.2 ng/ml, and 20.4+/-16.1 ng/ml, respectively. Serum visfatin (r=0.15, p=0.37) and fetuin-A (r=0.17, p=0.22) were not correlated with the CAC score, whereas plasma osteopontin level showed a moderate correlation with the CAC score (r=0.35; p=0.008). In ROC analysis, the area under the curve for identification of CAC was greatest for osteopontin (0.741; p=0.004), followed by fetuin-A (0.574; p=0.31), and visfatin (0.580; p=0.27). The cut-off value was 18.45 ng/ml for osteopontin, with a sensitivity of 72% and specificity of 73%. CONCLUSION: Our results suggest that there might be an association between CAC and plasma osteopontin levels. Research should continue to find out a metabolic parameter that will strongly indicate coronary calcification.