A case report of superior vena cava obstruction.

We report herein an 83-year-old gentleman with lung cancer who presented with nausea, complete atrioventricular (AV) block and presyncope. Despite a present temporary pacemaker, which had been inserted through the femoral vein 5 days previously, the patient had asystole attacks that resolved with atropine administration. Coronary angiography demonstrated no critical stenosis. Sick sinus syndrome was diagnosed, and permanent pacemaker implantation was decided. However, the guidewire could not be advanced into the superior vena cava (SVC). Right jugular venogram showed complete obstruction of the SVC. Subsequent computerized tomography also revealed its obstruction by a large lung tumor. Special attention should be given to patients with benign or malignant SVC syndrome before permanent pacemaker implantation.

Angiographic evaluation of the radial artery diameter in patients who underwent coronary angiography or coronary intervention.

OBJECTIVES: The aim of this study was to determine the radial artery diameter of patients through angiography and evaluate the feasibility of using wider sheaths for radial interventions. In addition, any parameters that could affect the radial artery diameter were also evaluated. BACKGROUND: The radial artery is a suitable, beneficial route for coronary procedures and is considered a good alternative to transfemoral access. However, a small radial artery diameter may make complicated coronary and peripheral procedures even more difficult. Therefore, an evaluation of the radial artery diameter may help the interventional cardiologist to select the instruments and techniques that are the most appropriate for the patient. METHODS: Radial artery diameters were calculated in 93 consecutive patients who underwent a transradial coronary procedure along with simultaneous radial angiography, and the anthropometric parameters that might affect the diameter and the association between vessel diameter and pain experienced by the patient during sheath removal were investigated. RESULTS: A total of 97 patients (69 males [71.1%]; 28 females [28.9%]) between 30-89 years of age (mean age, 59.0 ± 10.6 years) were included in the study. Four patients were excluded due to the failure of the radial procedure. The radial artery diameters were measured angiographically in the remaining 93 patients, and the procedural success rate was 95.8%. The mean radial artery diameters were 2.3 ± 0.38 mm in males, 2.1 ± 0.42 mm in females, and 2.3 ± 0.40 mm for the entire study population. Body weight and distal and proximal wrist diameters showed positive and significant correlations with the radial artery diameter (P=.025, P=.013, and P=.032, respectively). CONCLUSION: In this cross-sectional study, since the mean radial artery diameter was 2.3 ± 0.40 mm, the coronary procedures performed via the radial route can be deemed successful. Moreover, we found no independent predictors of radial artery diameter. Among the patients, 74% had coronary artery diameters of 6 Fr or larger. As long as the ulnar collateral circulation is sufficient, the transradial procedure can be safely performed without considering any other anthropometric parameters.

Quantitative evaluation improves specificity of myocardial perfusion SPECT in the assessment of functionally significant intermediate coronary artery stenoses: a comparative study with fractional flow reserve measurements.

OBJECTIVE: Myocardial perfusion SPECT (MPS) is a noninvasive method commonly used for assessment of the hemodynamic significance of intermediate coronary stenoses. Fractional flow reserve (FFR) measurement is a well-validated invasive method used for the evaluation of intermediate stenoses. We aimed to determine the association between MPS and FFR findings in intermediate degree stenoses and evaluate the added value of quantification in MPS. METHODS: Fifty-eight patients who underwent intracoronary pressure measurement in the catheterization laboratory to assess the physiological significance of intermediate (40-70%) left anterior descending (LAD) artery lesions, and who also underwent stress myocardial perfusion SPECT either for the assessment of an intermediate stenosis or for suspected coronary artery disease were analyzed retrospectively in the study. Quantitative analysis was performed using the 4DMSPECT program, with visual assessment performed by two experienced nuclear medicine physicians blinded to the angiographic findings. Summed stress scores (SSS) and summed difference scores (SDS) in the LAD artery territory according to the 20 segment model were calculated. A summed stress score of ≥ 3 and an SDS of ≥ 2 were assumed as pathologic, indicating significance of the lesion; a cutoff value of 0.75 was used to define abnormal FFR. Both visual and quantitative assessment results were compared with FFR using Chi-square (χ²) test. RESULTS: The mean time interval between two studies was 13 ± 11 days. FFR was normal in 45 and abnormal in 13 patients. Considering the FFR results as the gold standard method for assessing the significance of the lesion, the sensitivity and specificity of quantitative analysis determining the abnormal flow reserve were 85 and 84%, respectively, while visual analysis had a sensitivity of 77% and a specificity of 51%. There was a good agreement between the observers (κ = 0.856). Summed stress and difference scores demonstrated moderate inverse correlations with FFR values (r = -0.542, p < 0.001 and r = -0.506, p < 0.001, respectively). CONCLUSIONS: Quantitative analysis of the myocardial perfusion SPECT increases the specificity in evaluating the significance of intermediate degree coronary lesions.

The particular interactions of the traditional cardiovascular risk factors with different circulating specific leukocyte subtype counts in blood: an observational study.

OBJECTIVE: The pathogenesis of atherosclerosis is multifactorial, however the impact of inflammatory cells in this process is well known. Different traditional cardiovascular risk factors (CVRFs) may have specifically different effects on leukocyte subtype. Thus, these special interactions may induce different vascular involvement forms due to the altered endothelial damage and vascular repair mechanisms. The aim of the present study was to investigate whether there is any specific relationship between the leukocyte subtypes and the traditional CVRFs and to evaluate the independency of possible relationships. METHODS: The study had a cross-sectional observational design. The study population consisted of the patients who underwent coronary angiography with a suspicion of coronary artery disease (CAD) at our institution in an outpatient manner. We enrolled 677 consecutive eligible patients with CAD or normal coronary arteries (NCA) and investigated the associations of traditional CVRFs, demographic properties and biochemical parameters including fasting plasma glucose (FPG), creatinine, serum uric acid level (SUA) and lipids with total circulating inflammatory cell (WBC, leukocytes) and subtype counts including neutrophils (N), lymphocytes (L) and monocytes (M). As a dependent variable, total leukocyte count and subtypes, and neutrophil/lymphocyte ratio (N/L ratio) which has been found to being related with increased vascular risk and events were investigated in the groups determined by the presence or absence of CVRFs and CAD by the univariate analyses and then multiple linear regression analyses. RESULTS: When we performed multiple linear regression analyses to determine the independent associations of inflammatory cell subtypes, we have found that FPG had an independent incremental association with WBC (ß±SE:4.2±1.4, p=0.004) and N (ß±SE:4.2±1.2, p=0.001). Current smoking had an independent incremental association with WBC and all cell subtypes (for WBC, N, L, and M: ß±SE: 748±161, p<0.001; ß±SE: 556±136, p<0.001; ß±SE: 185±69, p=0.007; ß±SE: 38±20, p=0.061, respectively) and SUA had an independent incremental association with WBC (ß±SE: 115±43, p=0.008), N (ß±SE: 107±38, p=0.005) and M (ß±SE: 26±6, p<0.001). Hypertension had an independent incremental association with WBC (ß±SE: 431±140, p=0.002) and N (ß±SE: 315±118, p=0.008). Male gender had an independent incremental association with only M (ß±SE: 52±20, p=0.010). Family history of CAD had an independent decremental association with WBC (ß±SE: -327±139, p=0.019) and N (ß±SE: -326±121, p=0.007). Finally, age had an independent decremental association with WBC (ß±SE: -32±7, p<0.001) and L (ß±SE: -16±3, p<0.001). The N/L ratio was independently related with increased age (p<0.001), FPG (p=0.003) and SUA (p=0.012). CONCLUSION: Our study results demonstrate that leukocyte subtypes have different specific associations with traditional CVRFs. We found that FPG affects specifically N while SUA affects specifically N and M, and current smoking affects nonspecifically on all cell subtypes. While hypertension with N and male gender with M were specifically related, age and family history of CAD were only related to L. These different interactions may lead to different endothelial damage and vascular repair mechanisms.

[The relation of serum monocyte chemoattractant protein-1 level with coronary atherosclerotic burden and collateral degree in stable coronary artery disease]. / Serum monosit kemoatraktan protein-1 düzeyinin kararli koroner arter hastaliginda koroner aterosklerotik yük ve kolateral derecesi ile iliskisi.

OBJECTIVES: We investigated whether serum monocyte chemoattractant protein-1 (MCP-1) level predicted coronary atherosclerotic burden in patients with stable coronary artery disease and its relationship with coronary collateral grade. STUDY DESIGN: We prospectively included 196 patients (103 males, 93 females; mean age 59 ± 11 years) who underwent coronary angiography for stable angina pectoris. Serum MCP-1 levels were determined before coronary angiography. Coronary atherosclerotic burden was measured by the Gensini score, and coronary collateral development was assessed by the Rentrop classification. The patients were divided into four groups: those with normal coronary arteries (NCA); those with coronary lesions of <70% luminal obstruction; and those with coronary lesions of ≥ 70% luminal obstruction accompanied by a good or poor collateral grade. RESULTS: The mean serum MCP-1 level was higher in patients with coronary lesions compared to patients with NCA (129 ± 130 vs. 102 ± 55 pg/ml, p=0.048). Although there were no significant differences in the MCP-1 levels of patients with NCA, with <70% luminal obstruction, and those with a significant luminal obstruction and a poor collateral grade, patients with significant luminal obstruction and a good collateral grade had significantly higher MCP-1 levels compared to the remaining groups (p=0.016). However, in multivariate regression analysis, MCP-1 level was not independently associated with the Gensini score. CONCLUSION: Our findings suggest that serum MCP-1 level is higher in patients with coronary atherosclerosis, without a significant and independent association with coronary atherosclerotic burden. Significantly increased serum MCP-1 levels in patients with a good collateral grade may be an interesting issue of investigation.

Plasma neutrophil gelatinase-associated lipocalin levels in acute myocardial infarction and stable coronary artery disease.

INTRODUCTION: Inflammation and polymorphonuclear neutrophils are shown to be important in the pathogenesis of acute myocardial infarction (AMI). Neutrophil gelatinase-associated lipocalin (NGAL) is secreted from neutrophils and may increase the proteolytic activity within the atherosclerotic plaque. We aimed to investigate whether the plasma levels of NGAL are higher in patients with AMI compared with stable coronary artery disease (CAD). METHODS: The study population consisted of 128 eligible patients who underwent coronary angiography with the clinical diagnosis of CAD. Of the 128 patients included in the study, the diagnosis was ST-segment elevation myocardial infarction (STEMI) in 53 patients, non-ST-elevation myocardial infarction (NSTEMI) in 38 patients and stable CAD in 37 patients. Plasma level of NGAL was measured in all patients with an enzyme-linked immunosorbent assay method. We compared the plasma NGAL levels among the groups. RESULTS: We found higher plasma NGAL levels in patients with AMI compared with the patients with stable CAD (146 ± 23 vs. 101 ± 53 ng/ml, P<0.001). The plasma NGAL levels between the subgroups of AMI were similar (145 ± 23.9 vs. 145 ± 23.4 ng/ml, P=not significant). In multivariate analysis, the independent factors related to AMI were current smoking (P=0.024), extent and severity of coronary atherosclerosis (P=0.030), and NGAL levels. The plasma NGAL level was independently related to the existence of AMI (odds ratio: 1.045, 95% confidence interval: 1.019-1.072, P=0.001). In patients with plasma NGAL level above 127 ng/ml, we observed a 12 times higher incidence of AMI (odds ratio: 12.2, 95% confidence interval: 2.3-64, P=0.003). CONCLUSION: The plasma level of NGAL is higher in patients with AMI compared with the patients with stable CAD. This finding may suggest an active pathophysiological role for NGAL in development of acute coronary events.

Endothelial progenitor cells (CD34+KDR+) and monocytes may provide the development of good coronary collaterals despite the vascular risk factors and extensive atherosclerosis.

OBJECTIVE: Endothelial progenitor cells (EPC) have a regenerative role in the vascular system. In this study, we aimed to evaluate simultaneously the effects of EPC and inflammatory cells on the presence and the extent of coronary artery disease (CAD) and the grade of coronary collateral growth in patients with clinical suspicion of CAD. METHODS: This study has a cross-sectional and observational design. We enrolled 112 eligible patients who underwent coronary angiography consecutively (mean age: 59±9 years). The association of circulating inflammatory cells and EPC (defined by CD34+KDR+ in the lymphocyte and monocyte gate) with the presence, severity and extent of CAD and the degree of collateral growth were investigated. Logistic regression analysis was used to define the predictors of collateral flow. RESULTS: Of 112 patients 30 had normal coronary arteries (NCA, 27%, 55±9 years) and 82 had CAD (73%, 61±8 years). Among the patients with CAD, the percent degree of luminal stenosis was <50% in 12 patients; 50-90% in 35 patients; and ≥90% in the other 35 patients. Circulating inflammatory cells were higher (leukocytes, 7150±1599 vs 8163±1588 mm(-3), p=0.001; neutrophils, 4239±1280 vs 4827±1273 mm(-3), p=0.021; monocytes, 512±111 vs 636±192 mm(-3), p=0.001) and EPCs were lower (0.27±0.15% vs 0.17±0.14%, p<0.001; 21±15 vs 13±12 mm(-3), p=0.004) in CAD group than NCA group. When we investigated the collateral growth in patients having ≥90% stenosis in at least one major coronary artery, we found that the patients with good collateral growth had significantly higher EPC (0.22±0.17% vs 0.10±0.05%, p=0.009; 18±15 vs 7±3 mm(-3), p=0.003) in comparison to patients with poor collateral growth. Presence of EPC was associated with reduced risk for coronary artery disease (OR: 0.934, 95%CI: 0.883-0.998, p=0.018) and was an independent predictor for good collateral growth (OR: 1.295, 95%CI: 1.039-1.615, p=0.022). A sum of CD34+KDR-, CD34+KDR+ and CD34-KDR+ cells (192±98 mm(-3)), and a CD34-KDR- cell subpopulation within monocyte gate (514±173 mm(-3)) reached to highest counts in good collateral group among all study population. CONCLUSION: Endothelial progenitor cells can be mobilized from bone marrow to induce the coronary collateral growth in case of myocardial ischemia even in presence of the vascular risk factors and extensive atherosclerosis. This finding may be supportive to investigate the molecules, which can specifically mobilize EPC without inflammatory cells.

Relation between serum monocyte chemoattractant protein-1 and coronary collateral development.

BACKGROUND: The degree of coronary collateral development is not same in every patient with similar degree of coronary stenosis. In animal studies monocyte chemoattractant protein-1 (MCP-1) has been found to be related to collateral vessel development. In this study we investigated whether a higher serum MCP-1 level is related to better coronary collateral vessel development in patients with stable coronary artery disease. METHOD: Eighty-three patients with stable angina pectoris, who have at least one coronary stenosis equal to or greater than 70% at coronary angiography, were prospectively enrolled. Serum MCP-1 and vascular endothelial growth factor (VEGF) levels were studied. Coronary collateral development was graded according to the Rentrop method. Patients with grade 2-3 collateral developments were included in good collateral group and formed group I. The patients with grade 0-1 collateral developments were included in poor collateral group and formed group II. RESULTS: The serum MCP-1 level was significantly higher in good collateral group (288 ± 277 pg/ml vs. 132 ± 64 pg/ml; P<0.001). There was also a positive correlation between serum MCP-1 level and Rentrop score (r=0.39, P<0.001). The patients in the good collateral group also had a significantly higher number of coronary arteries with significant stenosis (1.7 ± 0.7 vs. 1.4 ± 0.6, P=0.049), and higher VEGF levels (322 ± 147 pg/ml vs. 225 ± 161 pg/ml, P=0.007). In multivariate analysis, only serum MCP-1 level (P=0.014, odds ratio: 1.01, 95% confidence interval: 1.002-1.019) was independently related to good coronary collateral development. CONCLUSION: Higher serum MCP-1 level is related to better coronary collateral development.

[Transradial approach in diagnostic and therapeutic interventional coronary artery procedures]. / Tanisal ve tedavi edici girisimsel koroner arter islemlerinde radiyal arter kullaniminin yeri.

Transradial access was first used in 1989 for diagnostic coronary angiography. With further improvements in the technique, it has gained wide popularity in percutaneous transluminal coronary angioplasty and percutaneous coronary interventions including stenting. When performed with appropriate indications, transradial approach is a preferable technique for coronary interventions due to lower rate of bleeding complications, increased patient comfort, shorter hospital stay and follow-up period, and decreased workload.

The association of circulating monocyte count with coronary collateral growth in patients with diabetes mellitus.

The status of inflammation may affect the collateral development in patients with diabetes mellitus (DM). Monocytes were found to have an important role in collateral growth in animal studies. We aimed to investigate the possible association of circulating monocyte count with collateral development in patients with DM and severe coronary artery disease (CAD). We enrolled 134 consecutive patients with DM who had > or =95 stenosis in at least one major coronary artery and investigated the relationship between circulating monocyte count and collateral growth. When we analyzed the coronary angiograms of eligible patients, we found that 64 of them had good collateral growth and 70 had poor collateral growth according to the Cohen-Rentrop method. The monocyte count was significantly different between good and poor collateral growth groups (643 +/- 184 vs. 479 +/- 143 per mm(3), P < 0.001). In the analysis comparing the Rentrop score with the Gensini score and circulating monocyte count, we found significant correlations (r = 0.293, P = 0.001 and r = 0.455, P < 0.001, respectively). The duration of ischemic symptoms tended to be longer in the good collateral group (1.9 +/- 4.1 vs. 0.8 +/- 1.3 years, P = 0.079). The Gensini score was also correlated with the duration of myocardial ischemic symptoms (r = 0.299, P = 0.004). Multivariate analysis revealed an increased monocyte count in the good collateral group [odds ratio (OR), 5.726; 95% confidence interval (CI), 1.817-18.040, P = 0.003, the cut-off value for monocyte was defined as 550 cell/mm(3)]. The increased circulating monocyte count in diabetic patients was evidently related to good coronary collateral growth. This finding may be potentially important in clinical and basic cardiovascular medicine.

[What is renin inhibition? Mechanism of action]. / Renin inhibisyonu nedir? Etki mekanizmasi.

After discovery of the first direct renin inhibitor, aliskiren, which blocks the renin-angiotensin-aldosterone system in the first rate limiting step, in addition to angiotensin-converting enzymes (ACE) and angiotensin-receptor blockers (ARB), renin has become an important target nowadays. The scope of this review is to give a detailed information regarding renin which has an important regulatory function in the body. It is crucial to understand renin and related structures in order to understand its functions in the organ systems. It is for sure that the ongoing trials will enlighten us more regarding the beneficial effects of renin inhibition in terms of morbidity and mortality.

The comparison of early and late outcome of direct and conventional stenting of patients with st elevation myocardial infarction.

BACKGROUND: The aim of this study was to compare direct and conventional stenting procedure in the subacute stable phase on short- and long-term results in patients with ST elevation myocardial infarction. METHODS: Eighty-eight clinically stable ST-segment elevation myocardial infarction (STEMI) patients were enrolled into the study. The patients were classified as group I (direct stenting) and group II (conventional stenting - stenting after balloon dilatation). Baseline characteristics of patients were scanned from hospital records. Coronary angiograms before and after the revascularization procedure were evaluated with the quantitative coronary angiogram technique. Patients were followed for 5 years for clinical outcomes. The study population consisted of 58 patients (65%) in group I and 30 patients (35%) in group II. Mean ages were 55.8 +/- 10.8 and 57.3 +/- 9.8, respectively. RESULTS: There were no significant differences between the two groups regarding clinical characteristics (hypertension, diabetes mellitus, family history of cardiovascular disease, smoking and dyslipidemia). The thrombus score was similar in both groups. Diameter stenosis was lower in group I (54.8 +/- 12.7 versus 61.4 +/- 12.6; p = 0.023) and TFC (Thrombolysis in Myocardial Infarction frame count) was higher in group II (30.7 +/- 14.5 versus 40.8 +/- 26.7; p = 0.02) before the percutaneous coronary intervention (PCI). Other quantitative angiographic parameters were not different. For all angiographic criteria, the difference between pre- and post-PCI parameters was significantly different in both groups. However, the change in TFC was higher within the group II compared to pre-PCI TFC rates. This difference was statistically significant (p = 0.002). Procedural success was statistically different between groups (69% in group I, 43% in group II; p50.01). Immediate clinical and angiographic results were similar. At 5-year follow-up the incidence of major adverse cardiac events including death, angina pectoris and myocardial infarction were similar for direct stenting versus conventional angioplasty. CONCLUSIONS: Direct stenting is safe and feasible for the treatment in patients with STEMI at the subacute phase. Immediate clinic, angiographic and late clinical results are similar for direct stenting and conventional stenting following balloon angioplasty. Although conventional stenting improved TFC better than direct stenting, this did not translate to better clinical outcomes.

The reliability of fractional flow reserve measurement in patients with diabetes mellitus.

BACKGROUND: Fractional flow reserve (FFR) is an invasive method to assess the functional significance of coronary stenoses. The value of FFR in diabetic patients is controversial because of microvascular dysfunction. The aim of this study is to investigate the effect of diabetes mellitus (DM) on FFR measurements. METHODS: One hundred and twenty-one patients with an intermediate lesion who had undergone FFR measurement were included in the study. Lesion severity was determined by quantitative coronary angiography. The patients were divided into groups according to the presence (group 1) or absence (group 2) of DM. The patients were further categorized according to the degree of luminal narrowing caused by the lesion (40-50, 51-60, and >60%) and reference vessel diameter (> or = 2.8 and <2.8 mm). FFR measurements were compared in each category. RESULTS: There was no difference between the FFR values of diabetic and nondiabetic patients who had coronary lesions with similar degree of luminal narrowing (0.87+/-0.08 vs. 0. 0.85+/-0.07; 0.81+/-0.08 vs. 0.82+/-0.10; 0.81+/-0.10 vs. 0.83+/-0.09, P = 0.957). In the analysis comparing FFR measurements in the categories set according to reference vessel diameter, we did not find a difference either (0.82+/-0.09 vs. 0.83+/-0.09; 0.84+/-0.09 vs. 0.82+/-0.09, P = 0.878). The DeltaFFR value, which is the difference between FFR values before and after adenosine administration, was also similar in diabetic and nondiabetic patients (8.4+/-6.0 vs. 8.4+/-5.5, P = 0.997). CONCLUSION: The presence of DM does not have a significant impact on FFR values in coronary stenoses of intermediate severity.

The impact of multiple vessel disease on fractional flow reserve.

BACKGROUND: Fractional flow reserve (FFR) is a method for the assessment of intermediate lesions. The impact of lesions at other coronary arteries on the FFR is not clear. We aimed to investigate the impact of the lesions in the other coronary arteries on FFR measurement. METHOD: FFR was performed in 113 patients with intermediate lesions at the left anterior descending artery. FFR values at baseline (FFRbase) and after adenosine administration (FFRmin) were detected. We divided the patients into groups according to FFRmin value. The first group consisted of 52 patients with a FFR < 0.80 and the second group consisted of 61 patients with a FFR > or = 0.80. We investigated the relationship between Gensini score and FFR values within the groups. RESULTS: A significant negative correlation was found in the analysis comparing Gensini score with FFRbase and FFRmin among the first group (r = -0.248, P = 0.009 and r = -0.685, P < 0.001, respectively). The relative FFR ratio was also significantly related with the Gensini score in the first group (r = -210, P = 0.047).When we divided the patients into 3 subgroups according to the number of the coronary arteries with significant lesion (> or = 70% stenosis) (group I: 1 vessel, group II: 2 vessels, group III: 3 vessels), we observed a relation with FFRbase (0.89 +/- 0.05 vs. 0.87 +/- 0.06 vs. 0.81 +/- 0.09, respectively, P = 0.007) and FFRmin (0.76 +/- 0.04 vs. 0.75 +/- 0.05 vs. 0.68 +/- 0.1 respectively, P = 0.002). In the second group, there was no relationship between Gensini score, FFR values and number of significantly diseased vessels. CONCLUSION: The overall extent and severity of coronary artery disease in a patient may affect the FFR measurement and may lead to misinterpretation of the lesion severity.

Long-term clinical effects of magnetic resonance imaging in patients with coronary artery stent implantation.

OBJECTIVES: We sought to investigate the early and late effects of magnetic resonance imaging (MRI) on stent thrombosis and major adverse coronary events after coronary artery stent (CAS) implantation at a long-term follow-up period. METHODS: Forty-three patients (28 men, mean age 63+/-10 years) who underwent CAS implantation before MRI examination were included. MRI was performed on a 1.5-T MR-system with a phased array multicoil. An average of 1.3 stents per patient were implanted (1-4 stents). More than one MRI was performed for two patients. Patients who underwent MRI within 8 weeks after the procedure were included in the early-term group (17 patients), and those who underwent MRI after 8 weeks were included in the late-term group (26 patients). RESULTS: Mean follow-up period was 36+/-15 months. There was no acute or subacute stent thrombosis. Late stent thrombosis that resulted in acute myocardial infarction was observed in a patient from the early group after an operation for prostate hyperplasia 5 months after MRI, and the patient underwent percutaneous coronary artery angioplasty. De-nova lesion was observed in four patients in the early group and two patients in the late group (P=0.14). In-stent restenosis was recorded in two patients in the early group and three patients in the late group (P=0.98). Composite major adverse cardiac events (acute coronary syndrome, myocardial infarction, death, and cerebrovascular event) were observed in seven of the early-group patients (41%), and in six of the late-group patients (23%) (P=0.20). CONCLUSION: MRI can be safely performed in patients with CAS implantation both in the early and late course, and is not associated with an increased risk of major adverse clinical cardiac events at long-term follow-up.

Impact of the lesion location on fractional flow reserve.

INTRODUCTION: Fractional flow reserve (FFR) is a method to determine the significance of a lesion. Although an FFR measurement of < 0.75 is accepted to show ischaemia, the effect of the location of the lesion on the coronary artery is not known. This study investigates the effect of lesion location on the FFR measurement. METHOD: Ninety-nine eligible patients who had undergone FFR measurement of an intermediate lesion (40-70% stenosis) at the left anterior descending coronary artery (LAD) were included. The lesions proximal to the origin of the first diagonal branch were accepted as proximal lesions and the remaining lesions were accepted as distal.The patients were categorized according to the degree of the percent diameter stenosis (40-50%, 50-60%, and > 60%) and the reference vessel diameter (RVD) (> or = 2.8 mm and < 2.8 mm). We compared the FFR measurements between proximal and distal lesions among different categories which were set according to anatomical features of the lesions. RESULTS: No significant difference was found between the FFR values of proximal and distal lesions with a similar percent diameter stenosis (0.86 +/- 0.08 vs. 0.83 +/- 0.08; 0.77 +/- 0.11 vs. 0.80 +/- 0.09; 0.75 +/- 0.07 vs. 0.77 +/- 0.08; P = 0.646).We did not find a difference between the FFR values of proximal and distal lesions with a similar RVD either (0.78 +/- 0.03 vs. 0.81 +/- 0.02; 0.84 +/- 0.03 vs. 0.81 +/- 0.01; P = 0.976). Major adverse cardiac event incidence was also similar for proximal and distal lesions (23% vs. 20%; P = 0.793). CONCLUSION: Fractional flow reserve can show the physiological significance of a stenosis independent of the anatomical location of the lesion on the coronary artery.

The optimal time of elective percutaneous coronary intervention for stable patients after ST elevation myocardial infarction.

OBJECTIVE: To find the optimal time (early: < or =3 days; late: >3 days) for revascularization in ST elevation myocardial infarction (STEMI) patients in the subacute phase. METHODS: Ninety-nine STEMI patients who were admitted to Gazi University Faculty of Medicine between 2000 and 2004 were enrolled into this study. Patients were divided into 2 groups according to time from the beginning of symptoms to the percutaneous coronary intervention. Coronary angiograms before and after the revascularization were evaluated using the quantitative coronary angiogram technique. RESULTS: 45 early (group I) and 54 late (group II) revascularized patients were evaluated. There were no significant differences between the 2 groups regarding demographic properties, thrombus score, success of the procedure, quantitative angiographic parameters, and clinical results of the procedure. CONCLUSIONS: Waiting for the development of stable phase in STEMI to apply PCI has no obvious benefit for angiographic and clinical results.

The delta fractional flow reserve can predict lesion severity and long-term prognosis.

BACKGROUND: Fractional flow reserve (FFR) is a method which is used to identify the angiographically intermediate lesions requiring revascularization. However, physiological importance and clinical usability of delta (Delta) FFR, the difference between FFR in baseline conditions (FFRbase, resting) and after adenosine administration (FFRmin, hyperemic), is currently unknown. We aimed to investigate whether DeltaFFR may be helpful in the identification of the lesion severity and predictability of long-term prognosis. METHOD AND RESULTS: We enrolled 123 consecutive patients with an intermediate lesion (40-70% stenosis) at LAD in this study. The patients were divided into three groups according to FFRmin results (group I: FFR>0.80, n=71; group II: FFR between 0.75 and 0.80, n=28; group III: FFR<0.75, n=24). We followed the patients for a mean duration of 36+/-17 months for major adverse cardiac events (MACE). For the sensitivity and the specificity of DeltaFFR to detect the lesion severity, the area under ROC curve was found as 0.873 (95% CI: 0.788-0.958, P<0.001). When >or=15 is accepted as the cut-off value for DeltaFFR, the specificity was 95%, the sensitivity was 59% for lesion severity. When we compared the predictability of MACE by FFRmin and DeltaFFR, there is no difference in FFRmin groups (FFR<0.75, 0.75-0.80 and FFR>0.80) (29%, 46% and 30%, respectively, P=0.247). However, between the groups which were determined according to cut-off values for DeltaFFR (DeltaFFR<10; DeltaFFR, 10-15; DeltaFFR>or=15) among the patients with FFR

Asymmetric dimethylarginine and coronary collateral vessel development.

INTRODUCTION: Nitric oxide (NO) plays a major role in collateral vessel development. Asymmetric dimethylarginine (ADMA) that is an endogenous inhibitor of NO synthesis may impair the effective coronary collateral vessel development. The aim of this study was to evaluate the relationship between plasma ADMA level and coronary collateral vessel development. METHODS: The patients with a greater than or equal to 95% obstruction in at least one epicardial coronary artery were included in the study. Degree of coronary collateral development was determined according to Rentrop method. Patients with grade 2-3 collateral development were regarded as good collateral group and formed group I. The patients with grade 0-1 collateral development were regarded as poor collateral group and were included in group II. Group III that had been formed as a control group included the patients with a normal coronary angiogram. We compared the plasma ADMA, symmetric dimethylarginine, L-arginine/ADMA ratio among three groups. RESULTS: Seventy-four patients have been included in the study. Patients with good collateral development had lower plasma ADMA level in comparison with patients with poor collateral development (0.41+/-0.25 micromol/l vs. 0.70+/-0.23 micromol/l, P=0.001) and had similar plasma ADMA levels with the patients who have normal coronary arteries. When we compared L-arginine/ADMA ratio between good and poor collateral groups, we found that the patients with higher L-arginine/ADMA ratio have significantly better collateral development (270.8+/-168.0 vs. 120.9+/-92.1, P<0.001). In the analyses comparing Rentrop score with ADMA level and L-arginine/ADMA ratio, there were significant correlations (r=-0.444, P=0.008 and r=0.553, P=0.001, respectively). In multivariate analysis, ADMA level (odds ratio, 0.009; 95% confidence interval, 0.000-0.466, P=0.020) and L-arginine/ADMA ratio (odds ratio, 1.010; 95% confidence interval, 1.001-1.020, P=0.032) were independent predictors of collateral development. CONCLUSION: Increased plasma ADMA levels are related with poor coronary collateral development. ADMA may be responsible for the difference in coronary collateral vessel development among different patients with coronary artery disease. NO inhibitors that have a determinative relation with endothelial cell functions may be integral prerequisite in all steps of collateral development.

Intracoronary thrombus aspiration through a guiding catheter in a case with stent thrombosis.

A 50-year-old male with a history of inferior myocardial infarction and stent implantation to the right coronary artery 20 days prior this admission presented with acute inferior myocardial re-infarction. Diagnostic right coronary angiography revealed a massive thrombus within the previously implanted stent. After manual aspiration through a guiding catheter, a large, fresh thrombus was removed. Subsequently, thrombolysis in myocardial infarction (TIMI) 3 flow was established, and no further intervention was required. The patient was discharged uneventfully on medical therapy.