Cardiohepatic syndrome and its prognostic predictive ability in patients with pulmonary arterial hypertension.

With the development of progressive right ventricular dysfunction, pulmonary arterial hypertension (PAH) is one of the causes of type 2 cardiohepatic syndrome (CHS). Risk assessment, timely and effective management are crucial to improve survival in PAH. Thus, we aimed to evaluate the presence of CHS at diagnosis and its association with prognosis in patients with PAH. One hundred and eighteen consecutive incident patients with PAH between January 2013 and June 2021 were retrospectively included. The presence of CHS was assessed from blood tests taken during diagnostic evaluation and was defined as elevation of at least two of three cholestatic liver parameters; total bilirubin, alkaline phosphatase and gamma-glutamyl transferase. The primary endpoint was all-cause mortality. Patients were followed for a median period of 58 (32-96) months. 23.7% of the patients had CHS at diagnosis. Significantly more patients in CHS (+) group were in intermediate and high-risk categories according to 2015 ESC/ERS guideline, REVEAL 2.0 and REVEAL Lite 2 risk assessment methods (p = .02, .03 and <.001, respectively). The presence of CHS was identified as an independent predictor of mortality (HR: 2.17, 95% CI: 1.03-4.65, p = .03) along with older age (HR: 2.89, 95% CI: 1.50-5.56, p = .001) and higher WHO functional class (HR: 2.57, 95% CI: 1.07-6.22, p = .03). To conclude, presence of CHS at diagnosis in patients with PAH was associated with severe disease and poor prognosis independent of other well known risk factors. As a simple and easy parameter to assess from routinely taken blood tests, CHS should be evaluated in patients with PAH.

Association of ectatic non-infarct-related artery with 1-month stent thrombosis in patients with ST elevation myocardial infarction.

BACKGROUND: Ectatic infarct-related artery (IRA) has been shown to be associated with higher thrombus burden, no-reflow, stent thrombosis (ST) and major adverse cardiovascular events in patients with ST-elevation myocardial infarction (STEMI). The effect of ectatic non-IRA on ST without ectatic IRA is not known. We aimed to assess the effect of ectatic non-IRA presence on ST within 1 month after primary percutaneous intervention (pPCI) in patients with STEMI. METHODS: A total of 1541 patients with a diagnosis of STEMI and underwent pPCI between 2015 and 2020 were retrospectively included in the study. Patients with and without 1 month ST were compared. Penalised logistic regression method was used to assess the association between ST and candidate predictors due to the risk of overfitting. RESULTS: Median age of the study group was 56.5 (48.7 to 67.2) years. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score, ectatic non-IRA presence and use of tirofiban were significantly higher in the ST group (18.2±9.9 vs 15.1±9.9, p=0.03; 25% vs 7.2%, p<0.001; 54.2% vs 30.5%, p<0.001; respectively). Significantly higher thrombus aspiration (14.3% vs 6.7%, p=0.03) and lower stent implantation (67.7% vs 84%, p<0.001) rates were observed in ectatic IRA group compared with ectatic non-IRA group. In multivariable analysis, ectatic non-IRA presence was independently associated with 1-month ST (OR 4.01, 95% CI 1.86 to 8.63, p=0.01). CONCLUSION: Ectatic non-IRA presence without ectatic IRA in patients with STEMI increases the risk of ST within the first month of pPCI.

Effects of RAAS blocker use on AKI in elderly hypertensive STEMI patients with propensity score weighed method.

Studies reported conflicting results on the effect of renin-angiotensin-aldosterone system (RAAS) blocker use on acute kidney injury (AKI) in patients undergoing elective coronary angiography but association in elderly patients with ST-elevation myocardial infarction (STEMI) is not known. Also, there are limited data on the effect of inflammatory markers on AKI. We aimed to investigate the effects of RAAS blocker pretreatment and inflammatory markers on AKI in this population. A total of 471 patients were compared according to presence of RAAS blocker pretreatment at admission. Conventional and inverse probability weighed conditional logistic regression were used to determine independent predictors of AKI. Mean age of the study group was 75.4 ± 7.1 years and 29.1% of the patients were female. AKI was observed in 17.2% of the study population. Weighted conditional multivariable logistic regression analysis revealed that AKI was associated with baseline creatinine levels and C-reactive protein/albumin ratio (CAR) (OR 2.08, 95% CI = 1.13-3.82, p = .02 and OR 1.19, 95% CI = 1.01-1.41, p = .04, respectively). No significant association was found between RAAS blocker pretreatment and AKI. CAR and elevated baseline creatinine levels were independent predictors of AKI in this patient group.

Vitamin D levels predict hospitalization and mortality in patients with heart failure.

OBJECTIVES: Low levels of vitamin D are closely associated with cardiovascular diseases. Heart failure (HF) is a major health problem globally, occurring with increasing frequency and characterised by poor prognosis despite therapy. We aimed to investigate the effect of vitamin D levels on hospitalisation and mortality in patients with HF. DESIGN: Patients with ejection fraction <50% (n = 219) were included in this prospective study. Demographic, clinical and laboratory parameters were obtained at presentation. Patients were classified into Group 1 (vitamin D level ≤50 nmol/L) and Group 2 (vitamin D level >50 nmol/L). Median follow-up time was 12 months. Hospitalisation rates and overall survival were compared between groups. Independent predictors of hospitalisation and mortality were defined. RESULTS: With a median follow-up period of 12 months, hospitalisation and overall death occurred more frequently in Group 1 than in Group 2 (23.4% vs 7.3% and 16.1% vs 1.2%, respectively; p < 0.005 for both).Vitamin D was defined as an independent predictor of hospitalisation and mortality.Higher levels were found to be associated with decreased hospitalisation (HR 0.89, 95% CI 0.84-0.95, p < 0.001) and mortality (HR 0.83, 95% CI 0.75-0.92, p < 0.001). CONCLUSIONS: Vitamin D deficiency is highly prevalent in patients with HF, and low vitamin D levels are closely associated with increased hospitalisation and mortality.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic atherosclerotic thrombi and ulcers.

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Association of contrast-induced nephropathy with bare metal stent restenosis in STEMI patients treated with primary PCI.

BACKGROUND: Contrast induced nephropathy (CIN) has been proven as a clinical condition related to adverse cardiovascular outcomes. However, relationship between CIN and stent restenosis (SR) remains unclear. In this study, we aimed to investigate the association of CIN with SR rates after primary percutaneous coronary intervention (PCI) and bare metal stent (BMS) implantation. METHODS: A total number of 3225 patients who had undergone primary PCI for STEMI were retrospectively recruited. The medical reports of subjects were searched to find whether the patients had a control coronary angiogram (CAG) and 587 patients with control CAG were included in the study. The laboratory parameters of 587 patients were recorded and patients who developed CIN after primary PCI were defined. Contrast induced nephropathy was defined as either a 25% increase in serum creatinine from baseline or 0.5 mg/dL increase in absolute value, within 72 h of intravenous contrast administration. RESULTS: The duration between primary PCI and control CAG was median 12 months [8-24 months]. The rate of SR was significantly higher in CIN (+) group compared to CIN (-) group (64% vs. 46%, p < 0.01). In multivariate Cox regression analysis, male gender, stent length, admission WBC levels and presence of CIN (HR 1.39, 95% CI 1.06-1.82, p < 0.01) remained as the independent predictors of SR in the study population. CONCLUSION: Gender, stent length, higher serum WBC levels and presence of CIN are independently correlated with SR in STEMI patients treated with BMS implantation.

Two- and live/real time three-dimensional transthoracic echocardiographic assessment of infective endocarditis of a valved pulmonary conduit.

We describe the use of a nonstandard left infraclavicular approach in making the diagnosis of an infected valved conduit with two-dimensional transthoracic echocardiography. The patient was an adult with tetralogy of Fallot and pulmonary atresia who had undergone multiple surgical repair procedures. The initial diagnosis of infective endocarditis was made by transesophageal echocardiography. Both techniques demonstrated a single, large vegetation in the conduit. Live/real time three-dimensional transthoracic echocardiography, on the other hand, provided further information by demonstrating several additional vegetations in the conduit and more comprehensively assessed their size by enabling measurement of their azimuthal dimensions and volumes. The patient was treated with antibiotics with complete resolution of the vegetations.

Transthoracic echocardiographic detection of pulmonary valve involvement in Löeffler's endocarditis.

We are describing pulmonary valve involvement with thickening and stenosis detected by two-dimensional transthoracic echocardiography in an adult presenting with Löeffler's endocarditis. To our knowledge, this has not been described previously. Complete regression of the lesions occurred with corticosteroid therapy. Tricuspid valve thickening and stenosis and thickening and thrombus formation in the right ventricle also present initially disappeared completely with therapy.

The advantages of live/real time three-dimensional transesophageal echocardiography in the assessment of tricuspid valve infective endocarditis.

Currently, tricuspid valve infective endocarditis (TVIE) is encountered in daily clinical practice more frequently due to the increasing prevalence of illicit intravenous drug use and the implantation of intracardiac devices. In this study, we compared findings from intra-operative live/real time three-dimensional transesophageal echocardiograms (3DTEE) and two-dimensional transesophageal echocardiograms (2DTEE) of 10 patients who underwent surgery for native tricuspid valve (TV) endocarditis. Unlike 2DTEE, 3DTEE allowed en face visualization of the 3 TV leaflets from both, atrial and ventricular aspects, in 9 of the 10 cases. In the remaining patient, in whom 3DTEE could not identify all 3 leaflets en face, the TV was found essentially destroyed at surgery. Using 3DTEE, the number of vegetations was accurately reported when compared with the surgical record. Furthermore, the orientation of each vegetation was the same as noted in the surgical findings. 2DTEE missed the identification of vegetations in 5 patients. The attachment site of vegetations to the TV were also not characterized by 2DTEE in 5 patients. In all 10 cases, 3DTEE characterized the vegetations more accurately with larger dimensions, including those in the azimuthal axis, and volumes. In addition, a perivalvular abscess that lead to surgical intervention was identified by 3DTEE, however, missed by 2DTEE. In conclusion, 3DTEE allows en face visualization of the TV apparatus permitting accurate description of the number and dimensions of vegetations identified by our surgical standard, which ultimately informs patients' prognosis and dictates the timing and planning for surgical intervention. Its use should be in conjunction with 2DTEE when evaluating TVIE.

Endoscopic Thoracic Sympathectomy in the Treatment of Vasospastic Angina Resistant to Medical Therapy.

BACKGROUND: In this study, we aimed to investigate the clinical follow-up results of endoscopic thoracic sympathectomy (ETS) in the treatment of vasospastic angina (VSA) resistant to maximal medical therapy. METHODS: A total of 80 patients with VSA who presented to our hospital between 2010 and 2022 were included in our study. Among them, 6 patients who did not respond to medical therapy underwent ETS. In-hospital and long-term clinical outcomes of patients who underwent ETS were recorded. RESULTS: The median age of the patients with VSA was 57 [48-66] years, and 70% of the group were males. In the ETS group, compared to the non-ETS group, higher numbers of hospital admissions and coronary angiographies were observed before ETS (median 6 [5-6] versus 2 [1-3], P <.001; median 5 [3-6] versus 2 [1-3], P =.004, respectively). Additionally, while 2 patients (33.3%) in the ETS group had implantable cardioverter defib-rillator (ICD), only 2 patients (2.7%) in the non-ETS group had ICD (P =.027). Out of the 6 patients who underwent ETS, 2 were females, with a median age of 56 [45-63] years. Four patients underwent successful bilateral ETS, while 2 patients underwent unilateral ETS. During the follow-up period after ETS, only 3 patients experienced sporadic attacks (once in 28 months, twice in 41 months, and once in 9 years, respectively), while no attacks were observed in 3 patients during their median follow-up of 7 years. CONCLUSION: It appears that ETS is effective in preventing VSA attacks without any major complications.

Rescue thrombolysis in the treatment of cardiac shock and acute stroke.

The patients with ST-elevation myocardial infarction are primarily managed with percutaneous coronary intervention (PCI) or thrombolysis. It is well accepted that rescue PCI should be implemented in case of unsuccessful thrombolysis. However, the reverse, rescue thrombolysis, that is, administering of thrombolytic therapy in a patient in whom primary PCI fails, is not well defined. There are no available data about rescue thrombolysis so far. We represent a 43-year-old male patient with Buerger disease (thromboangiitis obliterans) who was admitted to our emergency department for cardiac shock related to inferior and right ventricular ST-elevation myocardial infarction. He was found to have occlusion of both right coronary artery and left anterior descending artery and managed with rescue thrombolysis. It was subsequently recognized that he had concurrent stroke caused by posterior cerebral artery (PCA) occlusion and improved with thrombolysis. It is reported for the first time that rescue thrombolysis has been put into practice and yielded great result after unsuccessful primary PCI.

Two- and three-dimensional transthoracic echocardiography in the assessment of acquired ascending aortic aneurysm to pulmonary artery fistula.

Aorta to pulmonary artery fistula is an uncommon and potentially fatal condition. This case is of a 48-year-old Caucasian male with congestive heart failure and multiple aortic valve replacement surgeries who presented with an acquired ascending aortic aneurysm to pulmonary artery fistula diagnosed using two-dimensional transthoracic echocardiography via nonstandard imaging windows. Three-dimensional transthoracic echocardiography using live/real time three-dimensional color Doppler was used to assess the size of the opening of the fistula, providing additional value. This patient was surgically managed and is doing well 8 months postoperation.

Live/real time three-dimensional transesophageal echocardiographic assessment of ventricular septal volume and mass before and after myectomy in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common genetically transmitted cardiomyopathy. In patients resistant to medical management, myectomy is the surgical procedure of choice to reduce the symptoms of left ventricular outflow obstruction. Two-dimensional transesophageal echocardiography (2DTEE) has become part of the operative procedure by decreasing the incidence of postoperative complications. However, because of the three-dimensional geometry of left ventricular outflow tract, it is unable to comprehensively assess the location and severity of the obstruction and to provide accurate guidance during myectomy. In this study, 10 patients with HCM underwent live/real time three-dimensional transesophageal echocardiography (3DTEE) intra-operatively to measure the volume of the resected septum. This volume correlated well with the volume of the resected septal muscle directly obtained using a graduating cylinder containing water (r = 0.9, P < 0.000). 3DTEE may be potentially used as an adjunct to guide the surgeon in performing an adequate myectomy with a lower incidence of residual obstruction and complications such as an iatrogenic ventricular septal defect.

Cardiac device-related invasive aspergilloma assessed by live/real time three-dimensional transthoracic echocardiography.

Cardiac device-related infection caused by Aspergillus species is a rare finding associated with high mortality. Prompt recognition and treatment is imperative, but difficult as blood cultures are often negative and diagnosis requires a high index of suspicion. Live/real time three-dimensional transthoracic echocardiography (3DTTE) provides incremental knowledge in the characterization of valvular vegetations. Here, we provide a detailed description of an invasive cardiac device-related infection caused by Aspergillus fumigatus using 3DTTE. Findings described here highlight the role for 3DTTE in the prompt diagnosis of invasive cardiac Aspergillus infections as well as surgical planning in such cases.

Incremental value of three-dimensional transesophageal echocardiography over two-dimensional transesophageal echocardiography in the assessment of Lambl's excrescences and nodules of Arantius on the aortic valve.

In this retrospective study, we identified 7 cases where Lambl's excrescences were identified by two-dimensional transesophageal echocardiography (2DTEE) and also had live/real time three-dimensional transesophageal echocardiography (3DTEE) studies available for comparison. We subsequently assessed them for the presence of Lambl's excrescences (LE) and nodules of Arantius (NA) on the aortic valve. After their identification, we qualitatively and quantitatively organized our findings by number, cusp location, measurements, and orientation if applicable. A greater number of LE was found by 3DTEE than 2DTEE (19 vs. 11, respectively). In all 3DTEE studies, their cusp attachment site, their x-, y-, and z-axis measurements, and orientation were clearly visualized and described. Only 3DTEE studies provided confident visualization of the cusp attachment sites. Similarly, a greater number of NA was found by 3DTEE than 2DTEE (21 vs. 5, respectively). The triad of NA was visualized in all 3DTEE studies and each was described using its x-, y-, and z- axis measurements. Only three 2DTEE studies provided reliable identification of the NA. In conclusion, we present further evidence of the incremental value of 3DTEE over 2DTEE in the qualitative and quantitative assessment of cardiac structures including LE and NA on the aortic valve.

The Relationship between the Presence of Cardiohepatic Syndrome and Mortality in Heart Failure with Reduced Ejection Fraction.

OBJECTIVE: Heart failure (HF) is a major health burden that commonly affects liver function. Therefore, cardiohepatic syndrome (CHS) has been defined to describe the relationship between the heart and the liver. In this study, we aimed to evaluate the effect of CHS on long-term mortality in HF with reduced ejection fraction (HFrEF). METHODS: Patients followed at the outpatient HF clinic of our hospital with HFrEF between 2010 and 2018 were retrospectively analyzed. CHS was defined as elevation of at least two of three cholestasis parameters (total bilirubin, alkaline phosphatase, and gamma-glutamyl transferase) above the upper limit of normal. Patients were divided into two groups according to the presence of CHS. The endpoint was all-cause mortality. Patients were followed up for a median of 4.4 (3.3-5.9) years. RESULTS: A total of 469 patients were included in the study. The mean age of the group was 52.2 ± 11.9 years and 75.5% of the patients were males. About 22.4% (n = 105) of the patients had CHS. Patients with CHS were older and had more comorbidities than patients without CHS. Furthermore, significantly worse left and right ventricular functions were observed in CHS (+) group. All-cause mortality was significantly higher in CHS (+) group (61.9% vs. 19.5%, P < 0.001). Multivariate analysis revealed the presence of CHS (HR: 2.92, 95% CI: 2.09-4.07, P < 0.001) as an independent predictor of long-term mortality. CONCLUSION: The presence of CHS is associated with increased long-term mortality in outpatients with HFrEF. As an easy parameter to assess from routine laboratory parameters, CHS should be used to evaluate the long-term prognosis of patients with HFrEF.

Effect of Albumin-Bilirubin Score on Prognosis in Ambulatory Heart Failure Patients with Reduced Ejection Fraction.

OBJECTIVE: Heart failure (HF) often impacts liver function due to reduced cardiac output and increased venous congestion. The Albumin-Bilirubin (ALBI) score has recently been shown to possess prognostic value in patients hospitalized with HF. In this study, we aimed to evaluate the association of the ALBI score with long-term mortality in ambulatory HF patients with reduced ejection fraction (HFrEF). METHODS: Consecutive patients with HFrEF were included between 2014 and 2019. The ALBI score was calculated using the following formula: (log10 total bilirubin [mg/dL] × 0.66) + (albumin [g/dL] × -0.085). Patients were categorized into two groups: low ALBI (≤ -2.60) and high ALBI score (> -2.60). The endpoint was all-cause mortality. Patients were followed up for a median of 55 (42.6-68.4) months. RESULTS: A total of 417 patients were included in the study. The mean age of the group was 51.5 ± 11.9 years, and 74.8% of the patients were male. 36.5% (n = 152) of the patients were in the high ALBI score group. Patients with a high ALBI score were more likely to be in the New York Heart Association functional class III/IV. These patients had significantly higher N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, systolic pulmonary arterial pressure, and inferior vena cava diameter, along with worse right ventricular systolic function than patients with a low ALBI score. All-cause mortality was significantly increased in the high ALBI score group (41.4% vs. 27.2%, P = 0.003). Multivariate analysis revealed the ALBI score (HR 1.53, 95% CI 1.09-2.15, P = 0.02) as an independent predictor of long-term mortality. CONCLUSION: The ALBI score is associated with increased long-term mortality in outpatients with HFrEF. It can easily be evaluated and utilized as a liver dysfunction score in this patient group, providing prognostic information.

Body fat percentage and infarct size in patients with non-ST segment elevation myocardial infarction.

OBJECTIVE: Obesity is a global health problem that increases the risk of coronary artery disease (CAD). However in studies, it has been observed that when the disease develops, obese patients have a more favorable prognosis than leaner patients. This is called the "obesity paradox." This study aims to evaluate the effect of obesity assessed with body fat percentage (BFP) and relative fat mass (RFM) besides body mass index (BMI) on infarct size (IS) estimated from peak creatine kinase-MB (CK-MB) levels in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: Patients with a diagnosis of NSTEMI who underwent coronary angiography between January 2017 and January 2022 were retrospectively evaluated. Patients without available anthropometric data to calculate BMI, BFP, and RFM and serial CK-MB measurements were excluded from the study. BMI was calculated using weight(kg)/(height[m])2 formula. Patients were dichotomized as obese (BMI≥30 kg/m2) and non-obese (BMI<30 kg/m2) to compare baseline characteristics. BFP and RFM were calculated from anthropometric data. Linear regression analysis was performed to define predictors of IS. RESULTS: Final study population consisted of 748 NSTEMI patients (mean age was 59.3±11.2 years, 76.3% were men, 36.1% of the patients were obese). Obese patients were more likely to be female, hypertensive, and diabetic. Smoking was less frequently observed in obese patients. Peak CK-MB levels were similar among groups. Obese patients had higher in-hospital left ventricular ejection fraction, and less severe CAD was observed in coronary angiographies of these patients. Multivariable regression analysis identified diabetes mellitus, systolic blood pressure, white blood cell count, hemoglobin, and BFP (ß=-4.8, 95% CI=-8.7; -0.3, p=0.03) as independent predictors of IS. CONCLUSION: Higher BFP is associated with smaller IS in NSTEMI patients. These findings support the obesity paradox in this patient group, but further, randomized controlled studies are required.

Prognostic impact of cardiohepatic syndrome in patients with ST-segment elevation myocardial infarction.

Background: Cardiohepatic syndrome (CHS) indicates a bidirectional interaction between the heart and liver. This study was designed to evaluate the impact of CHS on in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention. Materials & methods: 1541 consecutive STEMI patients were examined. CHS was defined as the elevation of at least two of three cholestatic liver enzymes: total bilirubin, alkaline phosphatase and gamma-glutamyl transferase. Results: CHS was present in 144 (9.34%) patients. Multivariate analyses revealed CHS as an independent predictor of in-hospital (odds ratio: 2.48; 95% CI: 1.42-4.34; p = 0.001) and long-term mortality (hazard ratio: 2.4; 95% CI: 1.79-3.22; p < 0.001). Conclusion: The presence of CHS is a predictor of poor prognosis in patients with STEMI and should be evaluated during the risk stratification of these patients.

Peritoneal dialysis for refractory heart failure: A single-center experience.

INTRODUCTION: Heart failure (HF) is a disease associated with poor quality of life. Peritoneal dialysis (PD) can be an alternative in the treatment of these patients to overcome fluid overload. The objective of this study is to observe the effects of PD in refractory HF patients. METHODS: We conducted an observational study including 10 patients with refractory congestive HF. PD started solely for fluid overload. Patients' baseline parameters were compared with follow-up parameters. RESULTS: Median age was 57.5 (44.8-64.3) years. Median left ventricular ejection fraction was 20% (18.8-31.3), and all patients had right ventricular dysfunction. Median estimated glomerular filtration rate was 51.2 (43.8-101.3) ml/min/1.73 m2 . Two patients (20%) died during the follow-up period. New York Heart Association (NYHA) functional class decreased significantly from a median of 4 to 2,1 and 1 in the 3rd, 6th, and 12th months, respectively (p ≤ 0.01 for all from baseline). Number and length of hospitalization decreased significantly after treatment (number from a median of 3 to 0, p = 0.013; days from 50.5 to 0, p = 0.028). CONCLUSION: PD significantly reduced NYHA functional class, number and days of hospitalization for HF. It could be a reasonable option in chronic treatment of patients with refractory HF.