Management of Hyperkalemia in Heart Failure.

Hyperkalemia is a common electrolyte abnormality in heart failure (HF) that can cause potentially life-threatening cardiac arrhythmias and sudden cardiac death. HF patients with diabetes, chronic kidney disease and older age are at higher risk of hyperkalemia. Moreover, hyperkalemia is also often associated with the use of renin-angiotensin-aldosterone system inhibitors (RAASi) including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists and sacubitril-valsartan. In clinical practice, the occurrence of hyperkalemia is a major concern among the clinicians and often limits RAASi use and/or lead to dose reduction or discontinuation, thereby reducing their potential benefits for HF. Furthermore, recurrent hyperkalemia is frequent in the long-term and is associated with an increase in hyperkalemia-related hospitalizations. Therefore, management of hyperkalemia has a special importance in HF patients. However, treatment options in chronic management are currently limited. Dietary restriction of potassium is usually ineffective with variable adherence. Sodium polystyrene sulfonate is commonly used, but its effectiveness is uncertain and reported to be associated with intestinal toxicity. New therapeutic options such as potassium binders have been suggested as potentially beneficial agents in the management of hyperkalemia. This document discusses prevalence, predictors and management of hyperkalemia in HF, emphasizing the importance of careful patient selection for medical treatment, uptitration of the doses of RAASi, regular surveillance of potassium and treatment options of hyperkalemia.

Neopterin as a novel marker; well correlated with mortality and morbidity in patients with advanced systolic heart failure.

Objective: The aim of this study is research relation of serum neopterin level with mortality and morbidity due to systolic HF and also its role in diagnosis of patients with systolic HF. Material and methods: Eighty-one patients with systolic heart failure (HF group) and eighty-one age- and gender-matched healthy subjects (the control group) were enrolled in the study. Echocardiographic examination was performed accordingly. At the beginning of the study, serum B type natriuretic peptide (BNP), neopterin, and high sensitive C-reactive protein (hs-CRP) were measured accordingly. The subjects were followed for one year then after. Mortality rate and number of hospitalisation due to HF were recorded. Results: Age and gender distribution over the groups were statistically similar (p > .05). LVEF of the control and HF groups were 62 ± 3 and 27 ± 3%, respectively (p < .001). Average neopterin value of HF group was significantly higher than that of the control group (p < .001). Both hs-CRP and BNP values were well correlated to neopterin values (p = .667 and .778, respectively). There was a significant correlation between number of hospitalisation and neopterin values among patients in HF group (p = .008). Also among HF group, neopterin value of patients died within first year of follow-up (n = 29) was higher than that of patients survived beyond first year (n = 52 and p = .011). Conclusions: Neopterin is a biomarker reflecting ongoing inflammatory process in deteriorating heart. High level of serum neopterin concentrations was associated with mortality and morbidity in systolic HF.

Frequency of genetic polymorphism for adrenergic receptor beta and cytochrome p450 2D6 enzyme, and effects on tolerability of beta-blocker therapy in heart failure with reduced ejection fraction patients: The Beta GenTURK study.

OBJECTIVE: The present objective was to determine frequency of Arginine389Glycine (Arg389Gly) and Cytochrome p450 2D6*10 (Cyp2D6*10) polymorphism in cases of heart failure-reduced ejection fraction (HFREF), and to evaluate the influence of the polymorphisms in response to beta-blocker (BB) therapy. METHODS: A total of 206 HFREF patients and 90 healthy controls were prospectively enrolled. Genotypes for Arg389Gly and Cyp2D6*10 polymorphisms of the healthy controls and 162 of the 206 heart failure (HF) patients were measured, identified by polymerase-chain-reaction- and restriction-fragment-length-polymorphism analysis. HFREF patients and healthy controls were compared regarding Arg389Gly polymorphism. The HFREF patients were separated into 2 subgroups based on achievement of maximal target dose (MTD) of BB. RESULTS: When comparing frequency of genotype distribution for Arg389Gly polymorphism in HFREF patients to the healthy controls, a statistically significant association was observed with CC genotype and Glisin-Glisin (GG) genotype (p<0.001, odds ratio [OR]=16, confidence interval [CI]: 3.8-67.9 and p<0.001, OR=0.3, CI: 0.2-0.6). Frequency of genotypes for Arg389Gly and Cyp2D6*10 polymorphism were similar in patients who could or could not achieve BB MTD (p=0.13 and p=0.60, respectively). CONCLUSION: The frequency of Arg389Gly polymorphism in patients with HFREF in the present Turkish population differed from that of the healthy controls. However, neither Arg389Gly polymorphism nor Cyp2D6*10 polymorphism was associated with dose tolerability of BB therapy.

Left ventricular pseudoaneurysm perceived as a left lung mass.

Left ventricular pseudoaneurysm is a rare complication of aneurysmectomy. We present a case of a surgically treated left ventricular pseudoaneurysm, which was diagnosed three years after coronary artery bypass grafting and left ventricular aneurysmectomy. The presenting symptoms, diagnostic evaluation, and surgical repair are described.

Investigating the Impacts of Preoperative Steroid Treatment on Tumor Necrosis Factor-Alpha and Duration of Extubation Time underwent Ventricular Septal Defect Surgery.

BACKGROUND: Cardiopulmonary bypass is known to cause inflammatory events. Inflammation occurs due to many known important biological processes. Numerous mechanisms are known to be responsible for the development of inflammatory processes. Currently, there are many defined mediators as a tumor necrosis factor-α (TNF-α) playing an active role in this process. AIMS: This research was to investigate the effects of pre-operative steroid use on inflammatory mediator TNF-α and on time to extubation postoperatively in ventricular septal defect patients undergoing cardiopulmonary bypass surgery. STUDY DESIGN: Controlled clinical study. METHODS: This study included 30 patients. These patients were assigned into two groups, each containing 15 patients. 5 micrograms/kg methylprednisolone was injected intravenously 2 hours before the surgery to Group I, whereas there was no application to the patients in Group II. TNF-α (pg/mL) level was measured in arterial blood samples obtained at four periods including: the preoperative period (Pre TNF); at the 5(th) minute of cross-clamping (Per TNF); 2 hours after termination of cardiopulmonary bypass (Post TNF); and at the postoperative 24th hours in cardiovascular surgery intensive care unit (Post 24 h TNF). RESULTS: The mean cross-clamp time was 66±40 and 55±27 minutes in Group I and Group II respectively. No significant difference was found between the groups in terms of cross-clamp time (p>0.05). The mean time to extubation was 6.1±2.3 hours in Group I and 10.6±3.4 hours in Group II. Group I extubation time was significantly shorter than Group II. Group I TNF-α levels at Post TNF and Post24h TNF was lower than Group II. These differences are also statistically significant (p<0.05). CONCLUSION: There is a strong indication that preoperative steroid treatment reduced the TNF-α level together with shortens duration of postoperative intubation and positively contributes to extubation in ventricular septal defect patients operated in cardiac surgery with cardiopulmonary bypass. (ClinicalTrials.gov Identifier: TCTR20150930001).

Eosinophil count is related with coronary thrombus in non ST-elevated acute coronary syndrome.

BACKGROUND: White blood cells are reported as important not only in plaque vulnerability but also in thrombus formation and thrombus growth in acute coronary syndromes. Eosinophils contain granules that promote thrombus formation and thrombus growth in some heart diseases. In this study we aimed to investigate the relation of eosinophil count with coronary thrombus formation in patients with non ST-elevated acute coronary syndrome (NST-ACS). METHOD: A total of 251 consecutive patients were hospitalized in our hospital with a diagnosis of NST-ACS. Venous blood is collected for measurement of hematologic indices in all patients undergoing the coronary angiography. Coronary angiographies were performed in our clinic using the standard Judkins technique and angiographic assessment of the presence of thrombus was made. RESULTS: During coronary angiography, coronary thrombus was not detected in 82 patients (Group 1). In the coronary angiography of 169 patients, coronary thrombus was detected at various grades (Group 2). While the neutrophil count (6.84±1.94 vs. 5.53±1.37; P<0.001) and eosinophil count (0.257±0.125 vs. 0.163±0.114; P<0.005) was significnatly increased in the group with coronary thrombus, the lymphocyte count (1.87±0.66 vs. 2.00±0.70; P<0.001) was significantly decreased in the group with coronary thrombus as compared to the patient group without coronary thrombus. In the correlation analyzes; presence of coronary thrombus is correlated with total cholesterol, LDL-C, total CK, CK-MB, troponin, total number of diseased coronary, platelet count, neutrophil count, lymphocyte count and eosinophil count. On multivariate linear regression analysis, total leukocyte count, neutrophil count, lymphocyte count, eosinophil count, troponin and total cholesterol was found to be independent predictor of coronary thrombus in patients with NST-ACS. CONCLUSION: Beside the increased neutrophil count, increased eosinophil count in CBC should alert the clinician about coronary thrombus development in patients with NST-ACS in order to make early medical interventions at acute phase of the disease.

Microalbuminuria in untreated prehypertension and hypertension without diabetes.

OBJECTIVE: Hypertension (HT) and prehypertension (preHT) were independent predictors of cardiovascular diseases. Urinary albumin leakage is a manifestation of generalized vascular damage. B-type natriuretic peptide (BNP) is a vasoactive peptide secreted by left ventricle in response to myocytic stretch. We aimed to investigate relationship between microalbuminuria (MA) and BNP in untreated elevated blood pressures. METHODS: Of 105 untreated prehypertensive subjects (53 men, 52 women), 100 hypertensive subjects (51 men, 49 women) and 57 normotensive subjects (32 men, 25 women) none had history of diabetes. Urine albumin excretion was measured by immunoradiometric assay in morning urine sample. RESULTS: The prevalence of MA was higher in hypertensive group than in prehypertensive group and in normotensive group (Hypertensive group; 33.9%, prehypertensive; 25.9%, normotensive; 10%). Subjects with HT had higher prevalence of microalbminuria; larger body mass index, higher levels of triglycerides, blood glucose and creatinin were more common in subjects with HT than in those with preHT. In hypertensive group; patients with microalbuminuria had higher systolic blood pressure (SBP), BNP, LVMI and lower eGFR as compared to those without MA. MA was significantly correlated with LVMI, BNP and SBP. In multivariate regression analysis, SBP (ß: 0.361; P < 0.001), LVMII (ß: 0.267; P = 0.011) and BNP (ß: 0.284; P = 0.005) were independent variables associated with MA in hypertensives. In prehypertensive group; patients with microalbuminuria had higher SBP, BNP, LVMI and lower eGFR as compared to those without MA. MA was significantly correlated with LVMI, BNP and SBP. In multivariate regression analysis, SBP (ß: 0.264; P = 0.002), LVMI (ß: 0.293; P = 0.001) and BNP (ß: 0.168; P = 0.045) were associated with MA in prehypertensives. CONCLUSIONS: In preHT and HT, SBP, BNP and LVMI are associated with MA. In the evaluation of increased blood pressures, in case of increased BNP and LVMI, MA should be investigated even in prehypertensive stages. The subjects with increased blood pressures should get medical treatment to prevent the effects on vascular structure and myocardium even in prehypertensive phase.

The value of isovolumic acceleration for the assessment of right ventricular function in acute pulmonary embolism.

AIM: The aim of this study was to assess the value of tricuspid annulus myocardial isovolumic acceleration (IVA) in the assessment of right ventricular function in patients with acute pulmonary embolism (PE). METHODS: Fifteen patients (mean age 60.6±11.3 years) with acute PE were enrolled and a control group was formed of 15 patients with a similar mean age (60.3±11.5). Patients who were diagnosed with acute PE by thoracic computed tomography angiography underwent transthoracic echocardiography at the time of diagnosis and at one month after diagnosis. RESULTS: In the control group IVA was 2.8±0.2 m/s(2), while in the acute PE group, it was 2.0±0.1 m/s(2) at the time of diagnosis and 2.9±0.1 m/s(2) at the end of the first month. When IVA values of acute PE patients at the end of the first month were compared with their initial values and those of the control group, they had normalized (control and acute PE p<0.0001; control and PE at one-month follow-up p=0.983). CONCLUSION: In our study, IVA was shown to be a reliable marker of right ventricular systolic function in patients with acute PE.

Elevated high sensitivity C-reactive protein and uric acid levels in coronary artery ectasia.

AIM: The aim of this study is to examine uric asid (UA) and high sensitive C-Reactive protein (Hs-CRP) levels in patients with coronary artery ectasia (CAE). MATERIALS AND METHODS: Ninety-eight patients with isolated CAE (mean age 57.5±10.3), (group-I), 110 patients with CAD but without CAE (mean age 56.3±10.7), (group-II), and 105 patients with normal coronary angiographies (mean age 58.1±10.8), (group-III) were included in the study. Blood samples of all individual were taken after coronary angiography from an antecubital vein, the patients uric acid and Hs-CRP levels were assessed. The severity of ectasia was evaluated and categorized according to Markis. RESULTS: A significant difference was not seen in serum uric acid and Hs-CRP levels between CAE and CAD groups. However, relative to the control group, uric acid and Hs-CRP levels in CAE and CAD groups were higher to a significant degree (p=0.001, p<0.001, respectively), (p<0.001, p<0.001, respectively). The statistical significant was detected between subgroups type I and type IV, Hs-CRP and UA were statistically high in subgroup type I. (p=0.012, p=0.033, respectively) In multiple regression analysis, CAE and CAD were independently associated with UA (ß=0.76; p<0.001, ß=0.68; p<0.001, respectively) and Hs-CRP (ß=0.66; p<0.01, ß=0.62; p<0.01, respectively) along with diabetes mellitus (ß=0.61; p=0.039, ß=0.94; p=0.028, respectively). CONCLUSION: In conclusion, the blood uric acid and Hs-CRP values in our study have been observed to be higher in the individuals with coronary arteri ectasia in comparison to normal individuals, and the increase in these values were found to be parallel to the extent of the ectasia.

Aorta-to-Left Atrial Fistula Caused by Air Gun Pellet Cardiac Injury.

Abnormal communication between the ascending aorta and the cardiac chambers is rare, diverse in origin, and can be congenital or acquired. We report a case of a 10-year-old boy with acquired aorta-to-left atrial fistula associated with an air gun pellet injury and his successful treatment.

Comparison of inflammatory markers in non-dipper hypertension vs. dipper hypertension and in normotensive individuals: uric acid, C-reactive protein and red blood cell distribution width readings.

AIM: In this study, we investigated the relationship of increased inflammatory parameters (C-reactive protein - CRP), oxidative stress markers (serum uric acid - SUA) and red blood cell distribution width (RDW) with non-dipper hypertension (NDHT). MATERIAL AND METHODS: Among the individuals who presented to the cardiology clinic, 40 patients (32.5% male, 67.5% female; mean age: 54.4 ±7.1) who had hypertension and were diagnosed with NDHT through ambulatory blood pressure monitoring, 40 age- and sex-matched dipper hypertension (DHT) patients (25% male, 75% female, mean age: 54.2 ±7.0), and 40 normotensive individuals (42.5% male, 57.5% female, mean age: 51.9 ±9.0) were enrolled in the study. Peripheral venous blood samples were collected from all the patients in order to evaluate the hematological and biochemical parameters. All the assessed parameters were compared among the groups. RESULTS: The CRP, RDW and uric acid levels were observed to be significantly higher in the non-dipper hypertension group in comparison to the dipper hypertension patients and the normotensive population (p < 0.05). These parameters were also significantly higher in the dipper HT group compared to the normotensive population (p < 0.05). CONCLUSIONS: We found in our study that increased CRP, uric acid and RDW levels, which are indicators of increased inflammation and oxidative stress, are significantly higher in the non-dipper HT patients in comparison to the dipper HT patients and control group.

Disturbed Left Atrial Function is Associated with Paroxysmal Atrial Fibrillation in Hypertension.

BACKGROUND: Hypertension is the most prevalent and modifiable risk factor for atrial fibrillation. The pressure overload in the left atrium induces pathophysiological changes leading to alterations in contractile function and electrical properties. OBJECTIVE: In this study our aim was to assess left atrial function in hypertensive patients to determine the association between left atrial function with paroxysmal atrial fibrillation (PAF). METHOD: We studied 57 hypertensive patients (age: 53 ± 4 years; left ventricular ejection fraction: 76 ± 6.7%), including 30 consecutive patients with PAF and 30 age-matched control subjects. Left atrial (LA) volumes were measured using the modified Simpson's biplane method. Three types of LA volume were determined: maximal LA(LAVmax), preatrial contraction LA(LAVpreA) and minimal LA volume(LAVmin). LA emptying functions were calculated. LA total emptying volume = LAVmax-LAVmin and the LA total EF = (LAVmax-LAVmin )/LAVmax, LA passive emptying volume = LAVmax- LAVpreA and the LA passive EF = (LAVmax-LAVpreA)/LAVmax, LA active emptying volume = LAVpreA-LAVmin and LA active EF = (LAVpreA-LAVmin )/LAVpreA. RESULTS: The hypertensive period is longer in hypertensive group with PAF. LAVmax significantly increased in hypertensive group with PAF when compared to hypertensive group without PAF (p=0.010). LAAEF was significantly decreased in hypertensive group with PAF as compared to hypertensive group without PAF (p=0.020). A' was decreased in the hypertensive group with PAF when compared to those without PAF (p = 0.044). CONCLUSION: Increased LA volume and impaired LA active emptying function was associated with PAF in untreated hypertensive patients. Longer hypertensive period is associated with PAF.

Função Atrial Esquerda Prejudicada Associada com a Fibrilação Atrial Paroxística na Hipertensão / Disturbed Left Atrial Function is Associated with Paroxysmal Atrial Fibrillation in Hypertension

Fundamento: A hipertensão arterial é o fator de risco mais prevalente e modificável para a fibrilação atrial. A sobrecarga de pressão no átrio esquerdo induz alterações fisiopatológicas que ocasionam alterações na função contrátil e nas propriedades elétricas. Objetivo: Nesse estudo, o objetivo foi avaliar a função do átrio esquerdo em pacientes hipertensos para determinar a associação entre a função atrial esquerda e a fibrilação atrial paroxística (FAP). Método: Foram estudados 57 pacientes hipertensos (idade: 53 ± 4 anos, fração de ejeção do ventrículo esquerdo: 76 ± 6,7%), incluindo 30 pacientes consecutivos com FAP e 30 indivíduos de controle pareados por idade. Os volumes do átrio esquerdo (AE) foram medidos através do método biplano de Simpson modificado. Foram determinados três tipos de volume do AE: volume máximo do AE (AEVmax), contração atrial prematura do AE (AEVpreA) e volume mínimo do AE (AEVmin). Foram calculadas as funções de esvaziamento do AE. Volume total de esvaziamento do AE = AEVmax - AEVmin e a FEtotal do AE = (AEVmax - AEVmin)/AEVmax, volume de esvaziamento passivo do AE = AEVmax-AEVpreA, e a FE do AE = (AEVmax - AEVpreA)/AEVmax, o volume de esvaziamento ativo do AE = AEVpreA- AEVmin e a FE ativa do AE = (AEVpreA - AEVmin)/AEVpreA. Resultados: O período hipertenso é maior no grupo de hipertensos com FAP. O AEVmax aumentou significativamente no grupo de hipertensos com FAP quando comparado ao grupo de hipertensos sem FAP (p = 0,010). A FEAE diminuiu significativamente no grupo de hipertensos com FAP em comparação com o grupo de hipertensos sem FAP (p = 0,020). A' diminuiu no grupo de hipertensos com FAP quando comparado com hipertensos sem FAP (p = 0,044). ...

Background: Hypertension is the most prevalent and modifiable risk factor for atrial fibrillation. The pressure overload in the left atrium induces pathophysiological changes leading to alterations in contractile function and electrical properties. Objective: In this study our aim was to assess left atrial function in hypertensive patients to determine the association between left atrial function with paroxysmal atrial fibrillation (PAF). Method: We studied 57 hypertensive patients (age: 53±4 years; left ventricular ejection fraction: 76±6.7%), including 30 consecutive patients with PAF and 30 age-matched control subjects. Left atrial (LA) volumes were measured using the modified Simpson's biplane method. Three types of LA volume were determined: maximal LA(LAVmax), preatrial contraction LA(LAVpreA) and minimal LA volume(LAVmin). LA emptying functions were calculated. LA total emptying volume = LAVmax−LAVmin and the LA total EF = (LAVmax-LAVmin )/LAVmax, LA passive emptying volume = LAVmax− LAVpreA and the LA passive EF = (LAVmax-LAVpreA)/LAVmax, LA active emptying volume = LAVpreA−LAVmin and LA active EF = (LAVpreA-LAVmin )/LAVpreA. Results: The hypertensive period is longer in hypertensive group with PAF. LAVmax significantly increased in hypertensive group with PAF when compared to hypertensive group without PAF (p=0.010). LAAEF was significantly decreased in hypertensive group with PAF as compared to hypertensive group without PAF (p=0.020). A' was decreased in the hypertensive group with PAF when compared to those without PAF (p = 0.044). Conclusion: Increased LA volume and impaired LA active emptying function was associated with PAF in untreated hypertensive patients. Longer hypertensive period is associated with PAF. .

Association of P wave dispersion and left ventricular diastolic dysfunction in non-dipper and dipper hypertensive patients.

OBJECTIVE: Objective of this study was to investigate the correlation between P wave dispersion and left ventricular diastolic function, which are associated with the increased cardiovascular events in patients with dipper and non-dipper hypertensive (HT). METHODS: Eighty sex and age matched patients with dipper and non-dipper HT, and 40 control subject were included in this observational cross-sectional study. P wave dispersion was measured through electrocardiography obtained during the admission. The left ventricular LV ejection fraction was measured using the modified Simpson's rule by echocardiography. In addition, diastolic parameters including E/A rate, deceleration time (DT) and isovolumetric relaxation time (IVRT) were recorded. Independent samples Bonferroni, Scheffe and Tamhane tests and correlation test (Spearman and Pearson) were used for statistical analysis. RESULTS: P wave dispersion was found to be significantly increased in the non-dipper than in the dipper group (56.0±5.6 vs. 49.1±5.3, p<0.001). Pmax duration was found significantly higher (115.1±5.6 vs. 111.1±5.8, p=0.003) and Pmin duration significantly lower (59.0±5.6 vs. 62.3±5.3, p=0.009) in the non-dippers. Correlation analysis demonstrated presence of moderate but significant correlation between P-wave dispersion and left ventricular mass index (r=0.412, p=0.011), IVRT (r=0.290 p=0.009), DT (r=0.210, p=0.052) and interventricular septum thickness (r=0.230 p=0.04). CONCLUSION: P wave dispersion and P Max were found to be significantly increased and P min significantly decreased in the non-dipper HT patients compared to the dipper HT patients. P-wave dispersion is associated with left ventricular dysfunction in non-dipper and dipper HT.

Predictors of coronary collaterals in patients with non ST-elevated acute coronary syndrome: the paradox of the leukocytes.

AIM OF THE STUDY: Atherosclerosis represents active inflammation in which leukocytes play significant role. Coronary collateral development is a response to myocardial ischaemia. In this study we aimed to investigate the association of the leukocytes with coronary collateral development in patients with non ST-elevated acute coronary syndromes (NST-ACS). MATERIAL AND METHODS: A total of 251 consecutive patients were hospitalized in our hospital with a diagnosis of NST-ACS. The blood samples were collected 1-hour after admission to the hospital and peripheral leukocytes (neutrophils, monocytes and lymphocytes) were examined. All patients underwent coronary angiography. The coronary collateral vessels (CCV) are graded according to the Rentrop scoring system. RESULTS: Group 1 consisted of 146 patients with Rentrop 0 and Group 2 consisted of 105 patients with Rentrop 1, 2 and 3. The presence of CCV was significantly associated with neutrophil count, lymphocyte count, monocyte count and neutrophil-lymphocyte ratio (NLR). In subgroup analyses, higher NLR was significantly associated with good CCV development in patients with NST-ACS. CONCLUSIONS: Higher neutrophil count, monocyte count and NLR and lower lymphocyte count on admission, were associated with the presence of CCV in patients with NST-ACS. High NLR may predict good collateral development in patients with NST-ACS.

The prognostic value of arterial stiffness in systolic heart failure.

BACKGROUND: Increased arterial stiffness is an indicator of mortality. This study consists of an 18-month follow-up of the mortality in advanced heart failure patients with increased arterial stiffness. METHODS: The study followed up 98 patients with a diagnosis of heart failure in NYHA class III and IV (76 males, 22 females and mean age of 60 ± 12 years) with a left ventricular ejection fraction ≤ 35% as determined by the Simpson method. Augmentation index (Aix) and pulse wave propagation velocity (PWV) parameters were used as indicators of arterial stiffness. Aix and PWV values were measured by arteriography. RESULTS: 36 patients died. Both Aix and PWV were powerful determinants of mortality, independent of other prognostic variables (p = 0.013, OR: 0.805; p = 0.025, OR: 0.853). A cutoff value for Aix of -14.33 gave 91.2%, 80.3% sensitivity and specificity. A cutoff value for PWV of 11.06 gave 82.4%, 65.4% sensitivity and specificity mortality was predicted. Left ventricular ejection fraction (p = 0.008, OR: 0.859) and B-type natriuretic peptide (p = 0.01, OR: 0.833) was the other independent determinant of mortality. A significant difference was found in both Aix and PWV between the compensated measurements and decompensated heart failure measurements made in 70 patients (p = 0.035, p = 0.048). CONCLUSIONS: Measurement of arterial stiffness is a convenient, inexpensive and reliable method for predicting mortality in patients with advanced heart failure.

Evaluation of arterial stiffness for predicting future cardiovascular events in patients with ST segment elevation and non-ST segment elevation myocardial infarction.

BACKGROUND: Arterial stiffness parameters in patients who experienced MACE after acute MI have not been studied sufficiently. We investigated arterial stiffness parameters in patients with ST segment elevation (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). METHODS: Ninety-four patients with acute MI (45 STEMI and 49 NSTEMI) were included in the study. Arterial stiffness was assessed noninvasively by using TensioMed Arteriograph. RESULTS: Arterial stiffness parameters were found to be higher in NSTEMI group but did not achieve statistical significance apart from pulse pressure (P = 0.007). There was no significant difference at MACE rates between two groups. Pulse pressure and heart rate were also significantly higher in MACE observed group. Aortic pulse wave velocity (PWV), aortic augmentation index (AI), systolic area index (SAI), heart rate, and pulse pressure were higher; ejection fraction, the return time (RT), diastolic reflex area (DRA), and diastolic area index (DAI) were significantly lower in patients with major cardiovascular events. However, PWV, heart rate, and ejection fraction were independent indicators at development of MACE. CONCLUSIONS: Parameters of arterial stiffness and MACE rates were similar in patients with STEMI and NSTEMI in one year followup. The independent prognostic indicator aortic PWV may be an easy and reliable method for determining the risk of future events in patients hospitalized with acute MI.

Atrial septal defect closure: comparison of vertical axillary minithoracotomy and median sternotomy.

BACKGROUND: This study aims to evaluate whether or not the method of right vertical axillary minithoracotomy (RVAM) is preferable to and as reliable as conventional sternotomy surgery, and also assesses its cosmetic results. METHODS: Thirty-three patients (7 males, 26 females) with atrial septal defect were admitted to the Cardiovascular Surgery Clinic of Cukurova University from December 2005 until January 2010. The patients' ages ranged from 3 to 22. Patients who underwent vertical axillary minithracotomy were assigned to group I, and those undergoing conventional sternotomy, to group II. Group I and group II were compared with regard to the preoperative, perioperative and postoperative variables. Group I included 12 females and 4 males with an average age of 16.5±9.7. Group II comprised 14 female and 3 male patients with an average age of 18.5±9.8 showing similar features and pathologies. The cases were in Class I-II according to the New York Heart Association (NYHA) Classification, and patients with other cardiac and systemic problems were not included in the study. The ratio of the systemic blood flow to the pulmonary blood flow (Qp/Qs) was 1.8±0.2. The average pulmonary artery pressure was 35±10 mmHg. Following the diagnosis, performing elective surgery was planned. RESULTS: No significant difference was detected in the average time of the patients' extraportal circulation, cross-clamp and surgery (p>0.05). In the early postoperative period of the cases, the duration of mechanical ventilator support, the drainage volume in the first 24 hours, and the hospitalization time in the intensive care unit were similar (p>0.05). Postoperative pains were evaluated together with narcotic analgesics taken intravenously or orally. While 7 cases (43.7%) in group I needed postoperative analgesics, 12 cases (70.6%) in group II needed them. No mortality or major morbidity has occurred in the patients. The incision style and sizes in all of the patients undergoing RVAM were preserved as they were at the beginning. Furthermore, the patients of group I were mobilized more quickly than the patients of group II. The patients of group I were quite pleased with the psychological and cosmetic results. No residual defects have been found in the early postoperative period and after the end of the follow-up periods. All of the patients achieved functional capacity per NYHA. No deformation of breast growth has been detected during 18 months of follow-up for the group I patients, who underwent RVAM. CONCLUSION: To conclude, the repair of atrial septal defect by RVAM, apart from the limited working zone for the surgeon in these pathologies as compared to sternotomymay be considered in terms of the outcomes, and early and late complications. And this has accounted for less need of analgesics and better cosmetic results in recent years.

Coronary artery fistula presenting as unstable angina pectoris in patients with antiphospholipid syndrome.

The cardiovascular system is one of the primary targets in patients with antiphospholipid syndrome. The valves are the most frequently affected. Atherosclerosis and coronary thrombosis are also seen. The risk of acute coronary syndrome is 10 times higher in patients with APS. We present an APS patient case who was hospitalized with acute coronary syndrome and who was later found to have coronary artery fistula.