Improvements in quality of life in septuagenarians versus octogenarians undergoing trans-catheter aortic valve replacement.

BACKGROUND: Very elderly patients represent a distinct patient group in clinical setting in terms of a decision for trans-catheter aortic valve replacement (TAVR) when one considers the potential improvement in the quality of life (QoL) on one hand and the benefit to risk ratio on the other. This study aimed to compare functional and QoL outcomes of TAVR between octogenarians and septuagenarians. METHODS: This prospective cohort study included 136 elderly patients (70 to 89 years of age), who underwent transfemoral TAVR due to degenerative aortic stenosis. Patients were allocated into one of the following age groups: septuagenarians (n = 67) and octogenarians (n = 69). Preoperative and early postoperative clinical parameters were recorded. In addition, QoL of the patients was evaluated using SF-36 questionnaire preoperatively and six month postoperatively. RESULTS: Groups were similar in terms of early postoperative mortality and morbidity parameters. The mean New York Heart Association (NYHA) class improved after TAVR in both groups. In addition, all SF-36 norm-based scale and SF-36 summary scale scores improved significantly in both groups during the postoperative period. Postoperatively, physical functioning, general health and physical component summary scores were significantly better in the septuagenarian group (P = 0.02, 0.01, 0.03, respectively). CONCLUSION: Although the improvement in the QoL in terms of physical health was more marked in septuagenarians than in octogenarians, substantial benefits on the QoL and particularly on mental health seem to justify re-consideration of TAVR indications in the very elderly.

Early experience of percutaneous paravalvular leak closure using a novel Occlutech occluder.

AIMS: Paravalvular regurgitation is an important complication of mitral valve replacement. Although surgical repair is mostly recommended, it is associated with significant morbidity. On the other hand, percutaneous closure is a less invasive alternative approach. Percutaneous approaches to treatment of paravalvular prosthetic regurgitation have emerged recently. One of them is the Occlutech Paravalvular Leak Device. The aim of this study was to evaluate early and midterm outcomes of percutaneous paravalvular leak closure utilising a novel occluder. METHODS AND RESULTS: Twenty-one consecutive symptomatic patients who had moderate or severe paravalvular prosthetic regurgitation on transoesophageal echocardiography were included in the study. All the patients were clinically evaluated and found inoperable for surgery. They underwent transapical repair with the Occlutech Paravalvular Leak Device. The patients were followed for 17±5 months. Attempts were made to rectify 41 defects in 21 patients with 100% success. Mean procedure time was 76±40 min and fluoro-scopy time was 44±37 min. Early post-procedural outcome was uneventful in all cases, with ≥1 grade reduction in regurgitation in all of the patients. There was no mortality during hospital stay. There was one case of haemothorax in one patient and one case of pneumothorax in another. Post-implantation 90-day follow-up data were obtained for 19 patients, and 12-month data were obtained for 12 patients. No deaths due to any cause, stroke or surgery for prosthetic impingement, worsening or relapse of paravalvular leak during follow-up were recorded. One patient underwent reintervention and was treated successfully with the same occluder 11 months after the index procedure. CONCLUSIONS: The novel Occlutech Paravalvular Leak Device, which was designed specifically for mitral and aortic paravalvular regurgitation, is an additional, useful tool in the device armamentarium for the treatment of PVL.

New Markers in Atherosclerosis: Thrombospondin-2 (THBS-2) and Leukocyte Cell-Derived Chemotaxin-2 (LECT-2); An Immunohistochemical Study.

BACKGROUND Current research investigating the role of THBS2 and LECT-2 in atherogenesis is very limited. Therefore, we designed this study to demonstrate the role of THBS-2 and LECT-2 in atherosclerosis at the tissue level in fresh specimens. MATERIAL AND METHODS A total of 32 patients who underwent coronary bypass surgery were enrolled. Aortic wall punch biopsies were obtained at the site of proximal aortosaphenous bypass graft anastomosis. A specimen of left internal mammarian artery (LiMA) was taken from the segment just proximal to its anastomosis. The aortic tissue is representive of the atherosclerotic tisue, and LiMA tissue is representative of the non-atherosclerotic area. The specimens were painted with CD68 for macrophage, and THBS-2 and LECT-2 antibodies for immunohistochemical staining. RESULTS Aortic THBS-2 levels were significantly lower, whereas aortic LECT-2 levels were significantly higher when compare to LiMA (14.4±9.9 (5-30) and 36.9±13.0 (5-60) p: 0.0001 and 20.3±15.0 (5-60) and 20.8±13,8 (10-30) p: 0.0001, respectively). CD68+ and monocyte level correlated significantly with AHA atherosclerosis grade (p=0.01, r=0.45 and p=0.001, r=0.56, Spearman's test). CD68+ level correlated significantly with LECT-2 levels in atherosclerotic aortic tissue (p=0.026, r=0.392, Spearman's test), whereas aortic TSBN-2 levels were not. CONCLUSIONS The present study has taken the first steps to highlight new markers in atherosclerosis by using immunohistochemical method. The study results suggest that the tissue levels of THBS2 and LECT-2 may correlate with the stage of atherosclerosis.

Circadian Rhythm of Infarct Size and Left Ventricular Function Evaluated with Tissue Doppler Echocardiography in ST Elevation Myocardial Infarction.

BACKGROUND: We aimed to investigate the circadian rhythm on left ventricular (LV) function and infarct size, according to the onset of ST elevation myocardial infarction (STEMI), with echocardiography in patients with first STEMI successfully revascularised with primary percutaneous coronary intervention (PCI). METHODS: We conducted a retrospective analysis of 252 STEMI patients. Patients were divided into the four, six-hour periods of the day. Conventional and tissue Doppler imaging (TDI) echocardiography were performed within 48hours after onset of chest pain. The average of peak systolic myocardial velocities (Sm) in each of the four myocardial segments and LV ejection fraction (LVEF) were calculated. RESULTS: A negative linear correlation was shown between CK-MB levels and Sm (r= -0.209, p=0.001). There was an oscillation between time of day and average of Sm. The lowest Sm and largest infarct size were in the period of 06:00-noon compared with period of noon-18:00 and 18:00-midnight (p=0.029 and p=0.031, respectively). A secondary analysis showed that both LVEF and Sm were lower in the midnight-noon group compared with the noon-midnight group (44.9±7.3% versus 47.3±7.9%, p=0.018, and 7.6±1.4cm/s versus 8.2±1.6cm/s, p=0.003, respectively). CONCLUSIONS: This study has shown that there was a circadian rhythm of infarct size and LV function evaluated by echocardiography according to time of STEMI onset. The largest infarct size and poor LV function occurred in the midnight-noon period, in particular in the 06:00-noon period.

Endovascular therapy of acute ischaemic stroke by interventional cardiologists: single-centre experience from Turkey.

AIMS: We report our single-centre experience with the Solitaire AB self-expanding retrievable stent system in patients with acute ischaemic stroke. METHODS AND RESULTS: Demographic, clinical, and angiographic findings of thirty-eight consecutive patients with acute ischaemic stroke who underwent mechanical thrombectomy were evaluated retrospectively. The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 17.8±4.6. Nearly half of the patients had a middle cerebral artery (MCA) occlusion (45%). Both internal carotid artery and MCA occlusions were detected in five patients. Successful revascularisation (Thrombolysis in Cerebral Infarction [TICI] 2b and 3) was achieved in 34 of 38 (89%) patients; a TICI 3 state was observed in 24 (63%) patients. Almost three quarters of the patients (74.3%) improved by >5 points on the NIHSS at discharge, and 57.9% showed a modified Rankin Scale (mRS) score of ≤2 at 90 days. CONCLUSIONS: This single-centre experience with mechanical thrombectomy devices demonstrated that the procedure could be performed safely with high success rates by experienced interventional cardiologists in suitably equipped cathlabs.

Novel fibro-inflammation markers in assessing left atrial remodeling in non-valvular atrial fibrillation.

BACKGROUND: Structural remodeling is associated with the fibroinflammatory process in the atrial extracellular matrix. In the present study we aimed to investigate whether serum levels of new circulating remodeling markers differ in patients with atrial fibrillation (AF) compared to patients with sinus rhythm. MATERIAL AND METHODS: The study population included 52 patients diagnosed with non-valvular AF and 33 age-matched patients with sinus rhythm. Serum levels of Galectin-3, matrix metalloproteinase-9 (MMP-9), lipocalin-2 (Lcn2/NGAL), N-terminal propeptide of type III procollagen (PIIINP), Hs-Crp, and neutrophil-to-lymphocyte ratio (NLR) were measured. The left atrial volume (LAV) was calculated by echocardiographic method and LAV index was calculated. RESULTS: Galectin-3, MMP-9, and PIIINP levels were significantly higher in AF patients except NGAL levels (1166 pg/ml (1126-1204) and 1204 pg/ml (1166-1362) p=0.001, 104 (81-179) pg/ml and 404 (162-564) pg/ml p<0.0001, and 1101 (500-1960) pg/ml and 6710 (2370-9950) pg/ml p<0.0001, respectively). The NLR and Hs-CRP levels were also higher in AF (2.1 ± 1.0 and 2.7 ± 1.1 p=0.02 and 4.2 ± 1.9 mg/L and 6.0 ± 4.7 mg/L p=0.04, respectively). In correlation analyses, NLR showed a strongly significant correlation with LAVi, but Hs-CRP did not (p=0.007 r=0.247, Pearson test and p=0.808 r=0.025, Pearson test, respectively). Moreover, Galectin-3, MMP-9, and PIIINP had a strong positive correlation with LAVi (p=0.021 r=640, Spearman test and p=0.004 r=0.319 Pearson test, and p=0.004 r=0.325 Pearson test, respectively). CONCLUSIONS: Novel fibrosis and inflammation markers in AF are correlated with atrial remodeling. Several unexplained mechanisms of atrial remodeling remain, but the present study has taken the first step in elucidating the mechanisms involving fibrosis and inflammation markers.

Neutrophil-to-lymphocyte ratio and in-hospital mortality in patients with acute heart failure.

OBJECTIVES: Previous studies have demonstrated the role of inflammation in acute heart failure. The neutrophil-to-lymphocyte ratio was found to be a useful inflammatory marker for predicting adverse outcomes. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would be associated with increased mortality in acute heart failure patients. METHODS: The study cohort consisted of 167 acute heart failure patients with an ejection fraction <50%. The primary endpoint was in-hospital mortality, and the patients were divided into two groups according to in-hospital mortality. RESULTS: In a multivariate regression analysis, including baseline demographic, clinical, and biochemical covariates, the neutrophil to lymphocyte ratio remained an independent predictor of mortality (OR 1.156, 95% CI 1.001 - 1.334, p = 0.048). CONCLUSION: In conclusion, an elevated neutrophil-to-lymphocyte ratio seems to be a predictor of short-term mortality in patients with acute heart failure and a reduced left ventricular ejection fraction.

A giant right atrial villous myxoma with simultaneous pulmonary embolism.

INTRODUCTION: Primary cardiac tumors are rare and approximately three quarters of them are benign and up to half of the benign tumors are myxomas. Right atrial villous myxoma with pulmonary embolism is an unusual apparition. PRESENTATION OF CASE: A 29 year-old male was admitted to our outpatient clinic with progressive exertional dyspnea, chest pain and intermittent feeling faint. A giant right atrial villous mobile mass was detected by means of transthoracic echocardiography. To exclude possible pulmonary embolism, chest computed tomography scan was performed and showed filling defects in the branch of the pulmonary artery. The mass was totally resected. DISCUSSION: RA villous myxoma is a rare subtype in an unusual location with high potential of pulmonary embolism. Early surgery for villous myxoma has a great importance in order to reduce the risk of pulmonary embolism. CONCLUSION: 3D TEE should be a sufficient technique for diagnosis and evoluation of shape, size and origin of the cardiac mass an adequate guide to surgical treatment.

Neutrophil-to-lymphocyte ratio and in-hospital mortality in patients with acute heart failure

OBJECTIVES: Previous studies have demonstrated the role of inflammation in acute heart failure. The neutrophil-to-lymphocyte ratio was found to be a useful inflammatory marker for predicting adverse outcomes. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would be associated with increased mortality in acute heart failure patients. METHODS: The study cohort consisted of 167 acute heart failure patients with an ejection fraction <50%. The primary endpoint was in-hospital mortality, and the patients were divided into two groups according to in-hospital mortality. RESULTS: In a multivariate regression analysis, including baseline demographic, clinical, and biochemical covariates, the neutrophil to lymphocyte ratio remained an independent predictor of mortality (OR 1.156, 95% CI 1.001 - 1.334, p = 0.048). CONCLUSION: In conclusion, an elevated neutrophil-to-lymphocyte ratio seems to be a predictor of short-term mortality in patients with acute heart failure and a reduced left ventricular ejection fraction. .

Serum gamma-glutamyl transferase levels and in-hospital mortality in patients with acute heart failure.

BACKGROUND: Acute heart failure (AHF) is a major cause of hospitalisation, morbidity and mortality worldwide. Gamma-glutamyl transferase (GGT) is an enzyme responsible for the extracellular catabolism of antioxidant glutathione and a potential risk indicator of cardiac mortality. Limited data exists on the prognostic value of circulating levels of GGT in patients hospitalized due to AHF. AIM: To study the association between baseline GGT activity and in-hospital mortality in AHF patients. METHODS: The study cohort consisted of 183 AHF patients with left ventricular ejection fraction (LVEF) < 50%. The primary endpoint was in-hospital mortality. Patients were divided into two groups according to in-hospital mortality. The relationship between GGT activity and in-hospital mortality was tested using logistic regression models, adjusting for clinical characteristics and echocardiographic findings. RESULTS: After adjustment for possible confounders, GGT level was significantly related (OR 1.056, 95% CI 1.018-1.096, p = 0.04) to in-hospital mortality. CONCLUSIONS: Elevated GGT activity is an independent predictor of short-term mortality in patients with AHF and reduced LVEF.

Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure.

BACKGROUND: Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. MATERIAL AND METHODS: Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 µg/kg followed by a continuous infusion of 0.1 µg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-alpha, interleukin-1beta, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. RESULTS: Twenty male and 9 female patients with mean age of 60.2 ± 7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. CONCLUSIONS: Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.

Transcatheter trans-apical closure of paravalvular mitral and aortic leaks using a new device: first in man experience.

This report describes the first use of a new paravalvular leak (PVL) device designed specifically to close paravalvular mitral and paravalvular aortic leaks. The first patient had severe paravalvular mitral leak that was closed using the transapical route with a rectangular designed PVL device that has an oval waist for self-centering and the second patient had moderate paravalvular aortic leak that was closed with a square designed device that has a round waist for self-centering. Both patients had complete closure.

A new parameter predicting chronic total occlusion of coronary arteries: platelet distribution width.

Platelet distribution width (PDW) measures the variability in platelet size and is a marker of platelet activation. We investigated whether PDW is associated with the extent of coronary artery disease (CAD) and coronary total occlusions (CTOs). We studied 162 patients: 108 had a coronary lesion with a diameter stenosis of ≥50%, the CAD(+) group, and 54 patients had normal coronary anatomy, the CAD(-) group. The CAD(+) group was subdivided into CAD(+) CTO(+) and CAD(+) CTO(-) groups. Among patients with CAD, the CTO(+) group had a significantly greater PDW (%) than the CTO(-) group (16.9 ± 2.8, 15.4 ± 3.0, and 15.4 ± 1.9, respectively; P = .008). In a receiver-operating characteristic analysis, a PDW cut point of 15.7% was identified in patients with CTO(+) (area under curve = 0.64, 95% confidence interval 0.54-0.75). A PDW value of more than 15.7% demonstrated a sensitivity of 64% and a specificity of 66%. The PDW is a simple platelet index that may predict the presence of CTO.

Association between serum cystatin C levels and coronary slow flow.

We assessed the association between serum cystatin C (CysC) levels and coronary slow flow (CSF) phenomenon in patients who underwent coronary angiography. A total of 210 patients (mean age 55.6 ± 10.9 years; 100 females) were included. Patients were divided into 3 groups, (patients with CSF [group 2], with coronary artery disease [CAD; group 3], and without CAD [group 1]). Serum CysC levels in patients with CSF were significantly lower than those with and without CAD (912.5 ± 135.6, 820.4 ± 104.2, and 1343.4 ± 236.6 ng/mL in groups 1, 2, and 3, respectively; P < .001). Serum CysC levels correlated with the number of vessels with CSF and mean corrected thrombolysis in myocardial infarction frame count (Spearman correlation coefficient [r s] = .192, P < .001 and r s = .261, P < .001 respectively). In conclusion, patients with CSF have lower CysC levels; this could be a useful biomarker of CSF involvement in patients who undergo diagnostic coronary angiography.

A new prognostic evaluation of patients with acute ST-elevation myocardial infarction undergoing primary angioplasty: combined Zwolle and Syntax score.

BACKGROUND: The Zwolle score (Zs) is a validated risk score used to identify low-risk patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The Syntax score (Ss) is an angiographic score that evaluates the complexity of coronary artery disease. AIM: We aimed to create a simple risk score by combining these two scores for risk stratification in patients with STEMI undergoing primary PCI. METHODS: 299 consecutive STEMI patients (mean age 57.4 ± 11.7 years, 240 men) who underwent primary PCI were prospectively enrolled into the present study. The study population was divided into tertiles based on admission Zs and Ss. A high Zs (> 3) and high Ss (> 24) were defined as values in the third tertiles. A low Zs and low Ss were defined as values in the lower two tertiles. Patients were then classified into four groups: high Zs and high Ss (HZsHSs, n = 26), high Zs and low Ss (HZsLSs, n = 29), low Zs and high Ss (LZsHSs, n = 48), and low Zs and low Ss (LZsLSs, n = 196). In-hospital cardiacoutcomes were then recorded. RESULTS: In-hospital cardiovascular mortality was higher in HZsHSs (50%) compared to the HZsLSs (27.5%), LZsHSs (0%), and LZsLSs (0.5%) groups. After adjustment for potentially confounding factors, HZsHSs (OR 77.6, 95% CI 6.69-113.1, p = 0.001), and HZsLSs (OR 28.9, 95% CI 2.77-56.2, p = 0.005) status, but not LZsHSs and LZsLSs status, remained independent predictors of in-hospital cardiovascular mortality. CONCLUSIONS: STEMI patients with HZsHSs represent the highest risk population for in-hospital cardiovascular mortality.

Utility of the neutrophil to lymphocyte ratio for predicting in-hospital mortality after levosimendan infusion in patients with acute decompensated heart failure.

BACKGROUND: The aim of this study was to investigate the effect of a levosimendan infusion on hematological variables in patients with acute decompensated heart failure (ADHF). The predictive value of these variables for in-hospital mortality was also evaluated. METHODS: A total of 553 patients (368 males; mean age, 63.4 ± 14.9 years) with acute exacerbations of advanced heart failure (ejection fraction ≤ 35%) and treated with either dobutamine or levosimendan were included in this retrospective analysis. The patients that received levosimendan therapy were divided into two groups according to in-hospital mortality: group 1 (21%) included patients who died during hospitalization (n=45), while group 2 (79%) included patients with a favorable outcome (n=174) after levosimendan infusion. Changes in several hematological variables between admission and the third day after levosimendan infusion were evaluated. RESULTS: The demographic characteristics and risk factors of the two groups were similar. A comparison of changes in laboratory variables after the infusion of levosimendan revealed significant improvement only in those patients who had not died (group 2) during hospitalization. The neutrophil to lymphocyte (N/L) ratio after levosimendan infusion was an independent predictor of in-hospital mortality (odds ratio: 1.310, 95% CI: 1.158-1.483, p<0.001). In a receiver-operating characteristic curve analysis, a value of 5.542 for the N/L ratio after levosimendan administration was identified as an effective cut-off point for predicting in-hospital mortality (area under the curve=0.737; 95% confidence interval=1100-1301; p<0.001). CONCLUSIONS: Levosimendan treatment was associated with significant changes in hematological variables in patients with ADHF. A sustained higher N/L ratio after levosimendan infusion is associated with an increased risk of in-hospital mortality in patients with ADHF.

Endovascular therapy of acute ischemic stroke by interventional cardiologists: initial national experience.

OBJECTIVES: We report our initial experience with thrombectomy devices in patients with acute ischemic stroke. STUDY DESIGN: Demographic, clinical, and angiographic findings of 19 consecutive patients (7 females and 12 males; mean age 61.4±12.5 years) with acute ischemic stroke were evaluated retrospectively. RESULTS: The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 19.5±5.6. Middle cerebral artery was the occluded artery in all of the patients (proximal occlusion in 11, distal in 8 and tandem occlusions in 7 patients). Successful revascularization was achieved in 16 patients (84%). The mean NIHSS score was 8.4±8.2 at 24 hours after the procedure, and 60% of patients showed a modified Rankin scale score of ≤2 at 90 days. New occlusion by migrated emboli was observed in 2 (11%) cases. None of the patients had experienced post-procedural symptomatic intracerebral hemorrhage; 3 patients died during the three-month follow-up. In all patients, thrombectomy was performed with retrievable Solitaire AB stent system. CONCLUSION: This single-center experience with mechanical thrombectomy devices demonstrated that high success rates can be achieved by experienced interventional cardiologists in equipped cath labs throughout the country.