Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes.

BACKGROUND: In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). PATIENTS AND METHODS: In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. RESULTS: The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05). CONCLUSION: MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

The value of the Clinical SYNTAX Score in predicting long-term prognosis in patients with ST-segment elevation myocardial infarction who have undergone primary percutaneous coronary intervention.

BACKGROUND: The Clinical SYNTAX Score (CSS) combines anatomical and clinical risk assessment. OBJECTIVES: This study was designed to evaluate CSS as a predictor of prognosis in patients with ST-elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (p-PCI). METHODS: We evaluated 433 patients who were diagnosed with STEMI and underwent p-PCI. CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). The primary endpoints were defined as all-cause mortality, myocardial infarction, and cerebrovascular events over 15 months' follow-up. RESULTS: Primary endpoints were achieved in 9.2% of patients with CSS≤14, 12.5% of those with 1426 (P<0.001). Kaplan-Meier analysis showed that the CSS>26 group had a significantly higher incidence of primary endpoints [P (log-rank)<0.001]. CSS>26 was identified as an independent predictor for all-cause mortality, myocardial infarction, and cerebrovascular events (hazard ratio 3.58, 95% confidence interval 1.68-7.60, P=0.001). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). CONCLUSION: CSS may be better than the Sx score for predicting long-term prognosis in patients with STEMI undergoing p-PCI.

A retrospective analysis of long-term graft survival in 61 pediatric renal transplant recipients: a single-center experience.

BACKGROUND: Although short-term renal allograft survival in children has improved over the years, long-term graft outcomes remain unclear. In this study we report the characteristics and other variables that impact long-term kidney graft survival in children. MATERIAL AND METHODS: Records of 61 pediatric kidney transplant recipients (mean age: 14±3 years) performed at our institution between 1995 and 2011 were evaluated. Patients were divided into 2 groups (functional and non-functional grafts) to investigate the factors that impact graft survival. The groups were compared in terms of recipient characteristics, underlying disease, HLA status, immunosuppressive therapy, donor characteristics, acute rejection, and delayed graft function (DGF). Statistical significance was detected with the t and chi-squared tests (Pearson and Fisher's exact tests). Kaplan-Meier analysis was performed for graft survival. RESULTS: Overall graft survival at 1, 5, 10, and 15 years were 93%, 66%, 46%, and 41%, respectively. The median graft survival was 128.4 months (range: 3-188 months). Donor age, acute rejection, and DGF strongly predicted the chance of graft survival (p<0.05). CONCLUSIONS: It appears that several modifiable risk factors can partially account for poorer graft survival in pediatric kidney transplant recipients.

Assessment of left atrial mechanical functions in thyroid dysfunction.

INTRODUCTION:  Thyroid hormone deficiency can lead to the impairment of cardiac function. OBJECTIVES:  The aim of the study was to determine the left atrial (LA) mechanical function in patients with subclinical hypothyroidism (SHT) and overt hypothyroidism (OHT) and investigate associations of LA mechanical function with diastolic function.  PATIENTS AND METHODS:  Twenty­six patients with newly diagnosed SHT (mean age, 42.2 ±12.5 years), 21 patients with OHT (40.2 ±8.5 years) and 28 healthy volunteers (42.4 ±11.2 years) were enrolled in this study. Patients were evaluated by standard M­mode echocardiographic measurements, mitral Doppler flow analysis, and tissue Doppler parameters at the lateral, septal, and right ventricular annuli. LA volumes were measured using the disc method, and the parameters of LA mechanical function were calculated.  RESULTS:  The active emptying volume (AEV) and active emptying fraction (AEF) were significantly higher in the OHT and SHT groups compared with controls. The passive emptying volume and passive emptying fraction were lower in the OHT and SHT groups compared with controls, but the differences were not significant. The conduit volume and the E/A ratio were significantly lower in the OHT and SHT groups compared with controls. The lateral and septal E/Em were significantly higher in the OHT and SHT groups than in the control group, but the septal Em/Am was significantly lower. Diastolic function parameters showed significant associations with AEV and AEF.  CONCLUSIONS:  LA mechanical function is impaired in patients with thyroid dysfunction. Our findings suggest that this impairment is secondary to that of the left ventricular diastolic function.

Differences in sex, angiographic frequency, and parameters in patients with coronary artery anomalies: single-center screening of 25 368 patients by coronary angiography.

BACKGROUND: Although the prevalence of coronary artery anomalies varies in different series, the precise population frequency is unknown. MATERIALS AND METHODS: The medical records of all patients who underwent coronary angiography between January 2002 and August 2012 were retrieved, and 238 cases with coronary anomalies were evaluated. Unlike other studies, we compared several angiographic parameters (fluoroscopy time, number of images, and catheters used) in addition to frequency and sex data. RESULTS: The angiographic frequency of coronary artery anomalies was 0.94%. The most common coronary anomaly was a left anterior descending-circumflex artery originating from separate ostia (0.29%). The second most common anomaly was a right coronary artery (RCA) originating from the left sinus of Valsalva (sV) (0.23%). Overall, coronary artery anomalies (1.28 vs. 0.80%; P<0.001) and a left anterior descending-circumflex artery originating from separate ostia (41.3 vs. 25.3%, P=0.010) were more frequent in women than in men. The percentage of patients requiring more than two catheters during the procedure was significantly higher for an RCA originating from the left sV (45.7 vs. 16.7%, P<0.001) and in hypertensive patients (85.7 vs. 70.8%, P=0.015). On comparing the three most common coronary anomalies, an anomalous RCA originating from the left sV had a significantly higher value for at least one angiographic parameter. CONCLUSION: An anomalous RCA originating from the left sV is the most difficult type of anomaly to perform the ostial coronary cannulation during procedure. The results of this study may lead to the development of more suitable diagnostic catheters for an anomalous RCA originating from the left sV.

Can aortic elastic parameters be used for the diagnosis of volume overload in patients with end stage renal disease.

BACKGROUND: We aimed here to investigate hydration status by echocardiography in end stage renal disease (ESRD) patients. METHODS: 25 ESRD patients [15 males; mean age: 54.0±16.6 years; 13 hemodialysis; 12 peritoneal dialysis] were considered eligible for this study. We also examined 29 healthy volunteers as a control group (17 males; mean age: 46.5±12.8 years). Body composition analysis using the bioimpedance spectroscopy technique was performed for volume overload diagnosis. The ratio of extracellular water (ECW) to height was used as volume indices. The aortic elastic parameters were calculated by echocardiography. A correlation analyses was performed between the ratio of ECW to height indicating the volume overload and the aortic elastic parameters e.g. Aortic strain (AS), Aortic distensibility (AD) and Aortic stiffness index (ASI). RESULTS: The ratio of ECW to height that indicates volume overload in ESRD patients was considerably higher than that in the control group (10.25±1.98 L/m vs. 8.66±1.22 L/m, p=0.001). There was a negative correlation between the ratio of ECW to height and AS and AD and a positive correlation between the ratio of ECW to height and ASI. CONCLUSION: Given the importance of the diagnosis and follow up of volume overload, the results show that aortic elasticity measurements, being easy to perform and replicate, can be used for this purpose.

Left main coronary artery thrombus resulting from combined protein C and S deficiency.

Inherited hypercoagulopathies such as protein C and S deficiency usually lead to the formation of venous thrombi in clinical practice; however, they rarely lead to arterial thrombosis. It has been demonstrated that both protein C and S deficiency may lead to myocardial infarctions. However, our literature review revealed no reports of left main coronary artery thrombi caused by protein C and S deficiency. This paper presents a case of a left main coronary artery thrombus resulting from protein C and S deficiency in a young patient with normal coronary arteries.

Pigtail catheter fracture and embolization into the abdominal aorta: an extremely rare angiographic complication.

Coronary angiography is a widely used diagnostic method for coronary artery disease. In clinical practice, although complications of the procedure often involve the vascular access point, there is no previous report of the fracture and embolization of the distal tip of a pigtail catheter. Herein, we present the case of a 51-year-old woman whose left ventriculography was interrupted by fracture of the curved tip of a pigtail catheter, which remained at the renal artery level in the abdominal aorta.

Evaluation of atrial electromechanical delay and left atrial mechanical function in patients with obstructive sleep apnea : Cardiac involvement in patients with OSA.

OBJECTIVE: The aim of this study was to evaluate atrial electromechanical delay measured by tissue Doppler imaging and left atrial mechanical function in patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fourty-seven moderate-to-severe OSA patients who were newly diagnosed by polysomnography (Apnea-hypopnea index ≥ 15 events/h, 32 males, mean age 49.4 ± 11.5) and 30 patients who had no OSA in polysomnography (Apnea-hypopnea index < 5 events/h, 21 males, mean age 45.4 ± 9.1) were included in the study. Using tissue Doppler, diastolic functions, atrial electromechanical coupling were measured from the lateral mitral, septal, and tricuspid annulus. Inter, intra, and left atrial electromechanical delay were calculated (lateral-tricuspid, septum-tricuspid, lateral-septal). Left atrial volumes (maximal, minimal, and presystolic) were measured by the method of discs in the apical four-chamber view and were indexed to body surface area. Mechanical function parameters of the left atrium were also calculated. RESULTS: Interatrial, intraatrial, and left atrial electromechanical delays were significantly higher in the OSA group compared to the control group. Passive emptying fraction was significantly decreased, volume at the beginning of atrial systole and active emptying volume were significantly increased in OSA patients compared to the controls. The apnea-hypopnea index was significantly associated with interatrial and intraatrial electromechanical delay, passive emptying fraction, and conduit volume. CONCLUSIONS: Electromechanical delay was markedly prolonged and left atrial electromechanical function was impaired in untreated OSA patients. These impairments worsen with increasing severity of OSA.

The value of P wave dispersion in predicting reperfusion and infarct related artery patency in acute anterior myocardial infarction.

PURPOSE: The aim of this study is to investigate whether P wave dispersion (PWD), measured before, during and after fibrinolytic therapy (FT,) is able to predict successful reperfusion and infarct related artery (IRA) patency in patients with acute anterior MI who received FT. METHODS: Sixty-eight patients who presented with acute anterior MI were enrolled in the study. An electrocardiogram was performed before and at 30, 60, 90 and 120 minutes after the start of FT. PWD was defined as the difference between maximum and minimum P wave duration on standard 12-lead surface electrocardiogram. A multivariate logistic regression model was used to assess whether PWD was predictor of IRA patency and ST-segment resolution (STR) on electrocardiogram. RESULTS: PWD120 was significantly lower in patients with STR on electrocardiogram (38 patients) compared with those without STR (30 patients) (44.8±11.5 vs. 52.9±10.3 ms; p < 0.001). PWD120 was found to be significantly lower in patients with patent IRA (31 patients) compared to those with occluded IRA (37 patients) (42.3±9.7 vs. 53.5±10.6 ms; p < 0.001). Logistic regression analysis revealed that PWD120 significantly predicted STR and IRA patency. A ≥51.6 ms PWD120 can predict an occluded IRA with a 87% sensitivity, ≥51 ms PWD120 can predict no reperfusion with a 74% sensitivity. CONCLUSION: PWD values, which were higher than 51 ms and 51.6 ms in patients who received fibrinolytic therapy, can serve as a marker of failed reperfusion and occluded IRA. PWD values, in combination with other reperfusion parameters, can contribute to the identification of rescue PCI candidates.

A case of spontaneous multivessel coronary artery dissection presenting with acute myocardial infarction and ventricular tachycardia.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia. Multivessel SCAD is much rarer than single vessel involvement and acute coronary syndrome remains the most common clinical presentation of a patient with SCAD. It predominantly occurs in association with atherosclerosis or in the absence of atherosclerosis. We, hereby, present a case of spontaneous multivessel coronary artery dissection in a 35-year-old male patient presenting with chest pain and ventricular tachycardia following emotional stress and discuss the etiology and treatment options.

Investigation of the atrial electromechanical delay duration in Behcet patients by tissue Doppler echocardiography.

AIMS: To investigate the atrial electromechanical delay (EMD) duration that is a non-invasive predictor of atrial fibrillation (AF) in patients with Behcet's disease (BD). METHODS AND RESULTS: Thirty-eight Behcet's patients (24 females, 14 males; mean age: 43.6 ± 10.3 years) who were being followed in the dermatology or internal medicine department and 29 demographically matched controls (13 females, 16 males; mean: age 42.6 ± 11.1 years) were included in the study. The inclusion criteria were recurrent oral ulcerations and two of the following features: recurrent genital ulceration, eye lesions, skin lesions or positive pathergy skin test for Behcet's group. Using tissue Doppler imaging, atrial electromechanical coupling [time interval from the onset of P wave on surface electrocardiogram to the beginning of A wave interval with tissue Doppler echocardiography (PA)] were measured from the lateral mitral annulus (PA lateral), septal mitral annulus (PA septum), and right ventricular tricuspid annulus (PA tricuspid). The mean disease duration was 10.5 ± 7.7 years. The inter-atrial and intra-atrial EMD were significantly higher in the Behcet group than those in the controls (19.8 ± 8.2 vs. 13.1 ± 4.4 ms, P = 0.001; 11.5 ± 7.4 vs. 6.9 ± 3.7 ms, P = 0.02; respectively). The left atrial EMD was similar in both of the groups. However, the P(max) and PWD values were significantly higher in the BD group compared with those in the controls (120.5 ± 10.1 vs. 112.1 ± 5.9 ms, P < 0.0001; 44.9 ± 10.7 vs. 28.4 ± 5.9 ms, P < 0.0001; respectively). CONCLUSION: Atrial electromechanical conduction times were increased in the BD patients compared with those in the controls. The tendency of BD patients to go into AF can be easily and non-invasively detected using tissue Doppler echocardiography. These findings may be indicators for subclinical cardiac involvement.

Extreme QT interval prolongation caused by mad honey consumption.

An unusual type of food poisoning, mad honey poisoning, is a well-known phenomenon in the Black Sea region of Turkey. Mad honey poisoning can result in severe cardiac complications including sinus bradycardia, nodal rhythm, various degrees of atrioventricular blocks, and even asystole. However, no cases of long QT interval have been reported so far. This paper reports the first case of extremely long QT interval to be associated with mad honey consumption.

Prolonged P wave dispersion in pre-diabetic patients.

BACKGROUND: It is known that overt diabetes as well as chronic hyperglycaemia can lead to atrial fibrillation. A P wave dispersion (PWD) represents heterogeneity in atrial refractoriness. AIM: To investigate PWDs in patients with pre-diabetes. METHOD: Based on the results of examinations, 84 pre-diabetic patients (the pre-DM group; 50 female, 34 male; mean age 54 ± 8.6 years) who had no overt diabetes, coronary artery disease or hypertension, whose fasting blood glucose was higher than 100 mg/dL and/or whose 2 h glucose concentrations on an oral glucose tolerance test was in the range of 140 to 199 mg/dL, and 48 healthy volunteers (the non-DM group, 30 female, 18 male; mean age 51.7 ± 7.3 years) with no illnesses, were enrolled in this study. Standard 12-lead electrocardiograms of all patients were taken at 50 mm/s and 20 mm/mV standardisation. Maximum (P(max)) and minimum (P(min)) P-wave durations were measured. The PWD was defined as the difference between P(max) and P(min). RESULTS: The P(max) and PWD values were significantly higher in pre-DM compared to non-DM (104 ± 13 ms vs 98 ± 12 ms; p < 0.05, 42 ± 13 ms vs 34 ± 11 ms; p <0.01 respectively). A positive correlation was found between PWD and fasting blood glucose (r = 0.32; p < 0.01). There was no correlation between PWD and HbA(1c) levels (r = 19; p > 0.05). Multivariate regression analysis showed no relationship between PWD and age, left atrial diameter, E, A, E/A or HbA(1c). However, there was a relationship between PWD and fasting blood glucose. CONCLUSIONS: The P(max) and PWD are increased in pre-diabetic patients who have no coronary artery disease, hypertension or left ventricular hypertrophy

Influence of menstrual cycle on p wave dispersion.

Female gender is an independent risk factor for some types of arrhythmias. We sought to determine whether the menstrual cycle affects P wave dispersion, which is a predictor of atrial fibrillation. The study population consisted of 59 women in follicular phase (mean age, 29.3 ± 7.7 years) (group F) and 53 women in luteal phase (mean age, 28.1 ± 6.8 years) (group L). The ECGs of 35 patients (mean age, 26.4 ± 4.5) were obtained in both follicular and luteal phase. Both groups underwent a standard 12-lead surface electrocardiogram recorded at 50 mm/s. Maximal (Pmax) and minimal P wave durations (Pmin) were measured. P wave dispersion (PD) was defined as the difference between Pmax and Pmin. PD was significantly higher in group L than group F (46.6 ± 18.5 versus 40.1 ± 12.7; P < 0.05). Pmin was significantly lower in group L than group F (51.6 ± 12.1 versus 59.1 ± 12.1; P = 0.002). When we compared ECGs in different phases of the 35 patients, PD was significantly higher in luteal phase than follicular phase (53.2 ± 12.3 versus 42.8 ± 10.2; P < 0.05). Pmin was significantly lower in luteal phase than follicular phase (47.6 ± 6.6 versus 56 ± 10.1; P = 0.05). We detected a significant correlation between the day of the menses and PD (r = 0.27; P < 0.05). PD was increased in luteal phase compared to follicular phase, and this difference was more prominent as the days of the cycle progressed.

P-wave duration and dispersion in patients with coronary slow flow and its relationship with Thrombolysis in Myocardial Infarction frame count.

AIM: P-wave dispersion (PD), and duration has been reported to be associated with inhomogeneous and discontinuous propagation of sinus impulses. The aim of this study was to investigate the PD in patients with coronary slow flow (CSF) phenomenon. METHODS: Study population included 48 patients with angiographically proven normal coronary arteries and slow coronary flow in all 3 coronary vessels (group I, 36 men; mean age, 54 +/- 9 years) and 32 subjects with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 24 men, mean age, 53 +/- 10 years). Coronary flow rates of all patients and control subjects were documented by Thrombolysis In Myocardial Infarction (TIMI) frame count. All patients in group I had TIMI frame counts greater than 2 SD above those of control subjects (group II). The mean TIMI frame count for each patient and control subject was calculated by adding the TIMI frame counts for each major epicardial coronary artery and then dividing the obtained value into 3. The maximum and minimum P-wave duration (P(max) and P(min)) and PD were measured from the 12-lead surface electrocardiogram. Echocardiographic examination was also performed. RESULTS: There was no statistically significant difference between the 2 groups with respect to age, sex, hypertension, diabetes mellitus, hyperlipidemia, and cigarette smoking (P > .05). P-wave dispersion and P(max) of patients with CSF were found to be significantly higher than those of control subjects (39.4 +/- 17 vs 21.2 +/- 10 milliseconds and 121.6 +/- 17.1 vs 104.3 +/- 10.4 milliseconds, respectively; P < .0001). Moreover, we found a significant positive correlation between both P(max) and PD with mean TIMI frame count (r = 0.836 and r = 0.806, respectively; P < .0001). CONCLUSIONS: P-wave dispersion and P-wave duration both were found to be greater in patients with CSF than in controls.

Right ventricular thrombus with Behçet's syndrome: successful treatment with warfarin and immunosuppressive agents.

Behçet's syndrome is a chronic multisystem disease that presents with recurrent oral and genital ulceration and recurrent uveitis. Cardiac involvement is an extremely rare manifestation of this disorder. A 33-year-old man with Behçet's syndrome was admitted to our department with a history of cough, fever, chest pain, hemoptysis, and weight loss. Transthoracic and transesophageal echocardiography revealed a right ventricular thrombus. After 1 month of treatment with warfarin, cyclophosphamide, and corticosteroid, the intracardiac thrombus resolved.

N-terminal probrain natriuretic peptide predicts altered circadian variation in essential hypertension.

Diminished nocturnal blood pressure fall in nondipper hypertensive patients are closely associated with poor prognosis. N-terminal probrain natriuretic peptide can also identify poor prognosis in miscellaneous heart diseases. In this study, we aimed to clarify the association between probrain natriuretic peptide levels and diminished nocturnal blood pressure fall in patients with essential hypertension. Twenty-six consecutive nondipper (age: 53+/-8 years, 14 men) (group 1), and 26 dipper hypertensive patients (age: 52+/-9 years, 16 men) (group 2), based on ambulatory blood pressure monitoring, and age and sex-matched 28 normotensive participants (age: 50+/-11 years, 16 men) (group 3) were compared with each other. Although systolic and diastolic ambulatory blood pressure values were similar in hypertensives during the day, those at night were higher in group 1 (P<0.0001). Echocardiographic findings revealed that the left ventricular mass index was higher in both group 1 (184+/-47) and group 2 (142+/-39) compared with control participants (102+/-19) (P<0.0001), but ejection fraction and relative wall thickness were similar in all groups. The transmitral E-wave velocity decreased in group 1 (0.62+/-0.15 m/s) and group 2 (0.7+/-0.14 m/sec) compared with group 3 (0.95+/-0.22 m/s) (P<0.01). The transmitral E/A ratio decreased (0.71+/-0.12, 0.81+/-0.2 and 0.79+/-0.57, respectively P<0.05), and the transmitral E-wave deceleration time increased in group 1 (208+/-46, 203+/-38 and 169+/-42 ms, respectively, P<0.05). The isovolumic relaxation time increased (112+/-23, 110+/-18 and 86+/-11 m/s, respectively, P<0.01). Although group 1 and 2 have a similar number of patients with diastolic dysfunction (23/26 and 22/26, respectively, P>0.05), there were great differences between plasma probrain natriuretic peptide levels (88+/-20, 58+/-22 and 47+/-20 pg/ml, respectively, P<0.0001). In addition, serum uric acid (6.5+/-1.4, 5.3+/-1.5 and 5.0+/-1.9, respectively P<0.001), and creatinine levels (0.88+/-0.2 and 0.78+/-0.2 vs. 0.72+/-0.3, respectively P<0.05) were higher in group 1. These observations suggest that nondipper state may be related to the increase in left ventricular mass index and probrain natriuretic peptide levels and elevation in both plasma uric acid and creatinine levels. Serum probrain natriuretic peptide levels are found to be correlated with left ventricular mass index (Pearson's correlation 469 P<0.0001); but not creatinine (Pearson's correlation 188 P>0.05).

Permanent pacemaker lead implantation via azygous vein in a patient with silent superior vena cava syndrome.

Occlusion of the superior vena cava is a rare but serious complication of transvenous endocardial pacing. We describe an unusual approach for permanent pacemaker implantation using the azygous vein in a patient with occlusion of the bilateral total subclavian and innominate veins after previous bilateral pectoral pacemaker implantation. Endocardial pacing using the azygous vein with minimal invasive thoracotomy may be a good option for patients with inaccessible subclavian route.