The impact of percutaneous left atrial appendage closure on left ventricular diastolic function and natriuretic peptide levels.

OBJECTIVE: Although the efficacy and safety of left atrial (LA) appendage (LAA) closure in patients with atrial fibrillation (AF) have been well documented in randomized controlled trials and real-world experience, there are limited data in the literature about the impact of LAA closure on diastolic functions. The study aimed to examine the impact of LAA closure on diastolic function and natriuretic peptide levels in patients with AF. PATIENTS AND METHODS: Twelve non-valvular AF patients with high risk for developing cardioembolic stroke and contraindications to warfarin underwent LAA occlusion with the WATCHMAN device (Atritech Inc., Plymouth, MN, USA). B-type natriuretic peptide levels and detailed diastolic parameters (mitral inflow velocities, deceleration time (DT), flow propagation velocity (Vp), isovolumetric relaxation time (IVRT), mitral annular e', TE-e', IVRT/TE-e', E/Vp, E/e', pulmonary vein flow parameters consisting of S, D, and S/D) were evaluated at baseline and 45 days after LAA closure. RESULTS: The median age of the patients was 69 (54-78) years and 75% (n: 9) of them were male. All patients completed forty-five days of follow-up. Compared to the baseline values, E/Vp ratio and BNP levels (1.95 (0.94-3.32) vs. 2.37 (1.09-4.46), p= 0.015; 290.0 (90-1271) pg/ml vs. 322.00 (106-1635) pg/ml, p=0.018, respectively) increased, and pulmonary vein S wave and S/D ratio (0.67 (0.33-0.92) vs. 0.38 (0.23-0.91) m/sec, p=0.048; 1.62 (0.86-5.75) vs. 1.33 (0.11-3.35), p=0.019, respectively) decreased after LAA closure. CONCLUSIONS: In the present study, we demonstrated that patients with AF have shown impaired diastolic functions and elevated BNP levels after the percutaneous closure of the LAA.

Assessment of cardiac arrhythmias in patients with ankylosing spondylitis by signal-averaged P wave duration and P wave dispersion.

OBJECTIVE: Aortic regurgitation, conduction disturbances, increased myocardial fibrosis and pericarditis could be seen in ankylosing spondylitis (AS). However, less attention has been paid to supraventricular arrhythmias (SVA) and atrial conduction system changes. We aimed to assess SVA and conduction system changes in patients with AS. PATIENTS AND METHODS: Twenty-eight patients (24 men; mean age, 28.7 ± 5.7 years) with AS and 30 healthy volunteers (26 men; mean age, 29.3 ± 5.8 years) were enrolled. All subjects were evaluated by 24-hour ambulatory electrocardiogram, 12 lead standard electrocardiogram (ECG) for P wave dispersion (Pd), and signal-averaged ECG (SAECG) for P wave duration (SAPWD). RESULTS: SVAs were detected in 9 patients with AS (32%) and 3 controls (10%; p =0.02). Mean SAPWD (115.7±28.6 ms vs. 100.2 ± 18.7 ms, p =0.017) and mean Pd (11.9±4.8 ms vs. 9.3±3.6 ms, 0.023) was longer in patients with AS than the control group. When patient with AS were divided into 2 subgroups as patients with or without SVA, the Pd (16.2±5.0 vs. 9.9±3.2, p =0.001), SAPWD (151.4±7.8 vs. 98.7±16.1, p =0.001) and Bath ankylosing spondylitis disease activity index (BASDAI) (5.1±1.6 vs. 3.7±1.0, p =0.014) were significantly greater in the subgroup with arrhythmias compared to the subgroup without arrhythmias. There was a moderate positive correlation between BASDAI and SAPWD (r=0.622, p =0.001). There was also a moderate positive correlation between BASDAI and Pd (r=0.479, p =0.01). CONCLUSIONS: SVA were detected more frequently in AS than control group. SAPWD and Pd were prolonged in patients with AS. Clinical severity assessed with BASDAI had a positive correlation with prolongation of SAPWD and Pd.

Vasospastic angina in a patient with hyperthyroidism.

A 56-year-old man presented with typical angina pectoris lasting >20 min associated with precordial ST-segment elevation. Urgent coronary angiography showed critical stenosis in the proximal segment of the left anterior descending artery, which resolved with intracoronary nitrate application. He was subsequently diagnosed with hyperthyroidism secondary to exposure of iodinated contrast agent which is thought to be the cause of the coronary spasm. Symptoms resolved upon treatment with propylthiouracil, slow-release diltiazem, isosorbide mononitrate, and aspirin. This unusual case highlights the importance of considering hyperthyroidism in the differential diagnosis of chest pain and coronary artery spasm. We suggest routine thyroid function testing in patients with coronary spasm.

Severe limb pain suppresses chest pain in a patient with anterior myocardial infarction.

Cardiac complications of chest trauma range from arrhythmias and valvular avulsions to myocardial contusion, rupture, and--rarely--myocardial infarction. Herein, we described a 44-year-old male patient who presented to the hospital after receiving a blow from a fist directly to the chest and fingertip amputation during a fight; anterior myocardial infarction without any chest pain was coincidentally detected. Our case illustrates the importance of electrocardiography in the initial evaluation of patients with chest trauma and suspected injury to the coronary arteries.

Huge mediastinal mass surrounding the heart.

The clinical presentation of oncological malignancies may vary widely. Herein, we present a patient with a huge mediastinal mass surrounding the heart, which caused the right ventricle to collapse. The mass was diagnosed as T-cell lymphoblastic lymphoma. Treatment consisted of intrathecal prednisone, ARA-C, methotrexate, and the CHOP chemotherapy regimen. Transthoracic echocardiography revealed disappearance of the paracardiac mass in front of the right ventricle at the 2-month follow-up.

Evaluation of cardiac autonomic functions in patients with systemic lupus erythematosus.

BACKGROUND: Cardiovascular involvement is one of the leading causes of death among patients with systemic lupus erythematosus (SLE). In this study, we aimed to investigate cardiac autonomic functions in SLE patients. METHODS: We enrolled 36 patients (25 female; mean age 34.2 ± 10.2 years) with SLE and 32 healthy subjects (23 female; mean age 35.0 ± 10.3 years). All participants underwent 24-h Holter recording. Heart rate recovery (HRR) indices were calculated by subtracting first, second, and third-minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV), heart rate turbulence (HRT) and QT dispersion analysis. The mean SLE duration was 8.4 ± 4.0 years. RESULTS: According to the baseline demographic characteristics, both groups were similar with regard to age, gender, body mass index and left ventricular ejection fraction. Mean HRR1 (32.6 ± 10.9 vs. 42.5 ± 6.5, p = 0.038), HRR2 (51.0 ± 16.9 vs. 61.0 ± 10.8, p = 0.01) and HRR3 (52.8 ± 17.5 vs. 65.8 ± 9.8, p < 0.001) values were significantly higher in control group. When HRV was considered, SDNN, SDANN, RMSSD, PNN50 and high frequency (HF) component were significantly decreased in patients with SLE compared with healthy controls, but low frequency (LF) component and LF/HF were significantly higher in SLE patients. In addition, HRT onset and HRT slope values were significantly less negative in SLE patients. QT dispersion was significantly greater in SLE patients than healthy subjects (81.3 ± 15.8 vs. 53.2 ± 13.1, p < 0.001). CONCLUSION: Our study results suggest that cardiac autonomic functions are impaired in SLE patients despite the absence of overt cardiac involvement and symptoms. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired autonomic functions in patients with SLE.

Visualization of dual coronary artery fistulae drainage to the right ventricle by transthoracic echocardiography.

Coronary artery fistula is a rare abnormality of coronary circulation. It is mostly congenital but acquired forms can also occur. Fistulae are usually asymptomatic and can sometimes be visualized during cardiac imaging such as transthoracic echocardiogram, cardiac magnetic resonance imaging, coronary computed tomography angiography and coronary angiography.

Potential biomarkers for vascular damage in Alzheimer's disease: thrombomodulin and von Willebrand factor.

OBJECTIVES: Evidence regarding the vascular basis of Alzheimer's disease (AD) is growing. In vascular damage thrombomodulin tears of the cell wall and its level increases in the plasma. von Willebrand factor (vWF) is also thought to be a biomarker for vascular damage. The aim of this study was to examine the levels of vWF and thrombomodulin in AD as possible markers for vascular damage and to test their utility as an early biomarker in AD. DESIGN: Case-control study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: Twenty Alzheimer's disease patients free from vascular risk factors and 20 controls were enrolled in the study. MEASUREMENTS: Thrombomodulin and VWF levels of 20 AD patients and 20 controls were analyzed by commercial kits. RESULTS: Thrombomodulin levels were not different between Alzheimer's disease and control groups [median (range) = 4.25 (2.27-37.00) ng/ml in Alzheimer's disease and 3.55 (2.27-14.00) in control group, p=0.15]. Von Willebrand Factor antigen (%) levels were 188.5 (96-306) in Alzheimer's disease, and 181 (112- 284) in control group (p=0.74). CONCLUSION: Although vascular damage is thought to play role in the pathogenesis of AD, vWF and thrombomodulin failed to demonstrate the vascular damage in AD. Their utility to be used as early biomarkers of AD could not be shown.

The association between serum uric acid level and coronary artery disease.

OBJECTIVE: This study was designed to determine the relationship between serum uric acid level and the presence and severity of coronary artery disease (CAD). METHODS: A total of 1012 patients who underwent coronary angiography were included in this study. All patients were assessed for the presence of cardiovascular risk factors and ongoing medications. Serum uric acid and creatinine level, as well as a fasting lipid profile and fasting blood glucose, were measured in all patients before the procedure. The severity of CAD was assessed by the Gensini score. RESULTS: Of 1012 patients (mean age, 59.4 +/- 10.24 years), 680 were men (mean age, 58.7 +/- 10.5 years) and 332 were women (mean age, 61.0 +/- 9.51 years). Of the study patients, 703 (69%) were hypertensive, 292 (28.9%) were diabetic (DM), 304 (30%) had a smoking history, 306 (30%) had low high-density lipoprotein cholesterol levels and 350 (34%) had hypertriglyceridaemia. CAD was present in 689 (68%) patients who were assessed by coronary angiography. One-, two- and three-vessel disease was detected in 32.6%, 32.5% and 34.9% of the patients respectively; left main coronary artery lesion was detected in 15% of the patients. A statistically significant difference in the mean uric acid concentrations was found between the patients with or without CAD [380 +/- 121 micromol/l (6.39 +/- 2.04 mg/dl) vs. 323.5 +/- 83.2 micromol/l (5.44 +/- 1.40 mg/dl) p < 0.001]. Based on logistic regression analysis, the increased serum uric acid level was found to be associated with the presence of CAD in both men and women (p < 0.001). The increased serum uric acid level was also found to be associated with the severity of CAD in both men and women based on multivariate linear regression analysis (p < 0.001). CONCLUSION: In conclusion, serum uric acid level was found to be associated with the presence and severity of CAD.

Advanced age is associated with endothelial dysfunction in healthy elderly subjects.

BACKGROUND: Aging is associated with an increased risk for atherosclerosis in which endothelial dysfunction is an early marker. OBJECTIVE: The purpose of this study was to determine if endothelial function is altered with increasing age in healthy subjects. METHOD: The study population consisted of 30 elderly and 36 younger subjects free from major cardiovascular risk factors. Transthoracic echocardiography was performed for each subject to rule out structural heart disease. Endothelial function was evaluated by flow-mediated dilation (FMD) of the brachial artery via ultrasound. RESULTS: Baseline characteristics of the elderly and the younger group were similar, except for age (mean age: 71.3 +/- 5.8 vs. 26.5 +/- 7.2). Transthoracic echocardiography was normal in all subjects. FMD of the elderly group was significantly lower than the younger group (7.9 +/- 3.1 in the elderly, 10.8 +/- 1.9 in the younger group, p < 0.001). A negative relationship was found between FMD and age (r = -0.528, p < 0.001). CONCLUSION: It can be concluded that endothelial function detected by FMD declines with increasing age in healthy human subjects. Advanced age is a predictor of impaired endothelial function.

Determining the relationship between metabolic syndrome score and angiographic severity of coronary artery disease.

BACKGROUND: Cardiovascular disease is leading cause of mortality and morbidity in developed and developing countries. Metabolic syndrome (MS) is a risk factor for coronary artery disease (CAD). The effect of MS on angiographic severity of CAD is not well defined. The aim of this study was to examine the effect of MS on angiographic severity of CAD by using Gensini score. METHODS: The total number of 1003 patients who underwent elective coronary angiography in catheter laboratory were included in the study. MS score based on National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria which ranged between zero and five were calculated for each subject. Gensini scores were determined by examining coronary angiograms of the patients. RESULTS: The study population consisted of 634 (63%) male, and 369 (37%) female subjects. The mean age was 59 +/- 11. MS based on NCEP ATP III was present in 246 (25%) patients. CAD was present in 691 patients (69%). The median of Gensini score was five (0-192) in the total sample, 18 (1-192) in the patients with CAD and 25 (0-192) in the patients with MS. A positive correlation was found between MS score and Gensini score (r = 0.402, p < 0.001). CONCLUSIONS: In this study, it was determined that as the severity of MS increases, the angiographic severity of CAD increases as well. Besides, the most important factor on Gensini score was diabetes mellitus in male and hypertension in female subjects.

Autoimmune polyendocrine syndrome with atrial septal defect.

Atrial septal defect is frequently reported with genetic syndromes. But, to the best of our knowledge, it has not been reported with autoimmune polyendocrine syndrome. Here, the case of a 44-year-old-woman with concomitant involvement of the salivary gland, thyroid, intestines, and, possibly endocrine pancreas, diagnosed with autoimmune polyendocrine syndrome type II, is reported with accompanying atrial septal defect. Celiac disease, Hashimoto thyroiditis, and Sjögren syndrome were symptomatic and laboratory confirmed diagnosis; anti-glutamic acid decarboxylase antibody was positive but asymptomatic for type-1 diabetes. She was known to have sinus venosus type atrial septal defect diagnosed at 38 years old, when she had tiredness and chest pain.

Myocardial delayed enhancement imaging: comparison of two-dimensional and three-dimensional inversion prepared fast gradient echo and steady state free precession sequences.

We compared two-dimensional (2D) and three-dimensional (3D) inversion recovery prepared (IR) fast gradient echo (FGRE) and steady state free precession (SSFP) sequences used in myocardial delayed enhancement imaging. Twenty patients with a prior history of acute coronary syndrome were included in this study. Breath hold, ECG gated, segmented 2D and 3D IR_FGRE and SSFP sequences were acquired after intravenous administration of 0.15 mmol/kg gadodiamide-DTPA. Overall image quality, transmural extent of myocardial infarction, infarct volume, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and signal intensity ratio (SIR) were calculated and compared for each technique. 3D IR trueFISP showed significantly higher mean values of SNR and CNR compared with 3D IR turboFLASH, 2D IR turboFLASH and 2D IR trueFISP (p < 0.04 and p < 0.001). 3D IR_FGRE showed the second highest SNR and CNR. 3D IR_SSFP and 3D IR_FGRE allowed the imaging of the whole heart within a single breath-hold which reduced the imaging time significantly compared to 2D IR_FGRE and 2D IR_SSFP. 3D IR_SSFP and 3D IR_FGRE offer higher SNR, CNR and rapid acquisiton compared to 2D IR_SSFP and 2D IR_FGRE with adequate image quality.

Bronchial to coronary artery fistulas: an important sign of silent coronary artery disease and potential complication during bronchial artery embolization.

Coronary artery fistulas are rare and usually asymptomatic congenital anomalies generally diagnosed incidentally during coronary angiographies. Herein, we present a case of bronchial to coronary artery fistula which was diagnosed incidentally during bronchial artery embolization. Embolization was performed successfully without complication, and an underlying important coronary artery stenosis was subsequently found by coronary computed tomography angiography.