The Interplay between Features of Plaque Vulnerability and Hemodynamic Relevance of Coronary Artery Stenoses.

Fractional flow reserve (FFR) may not be immune from hemodynamic perturbations caused by both vessel and lesion related factors. The aim of this study was to investigate the impact of plaque- and vessel wall-related features of vulnerability on the hemodynamic effect of intermediate coronary stenoses. Methods and Results: In this cross-sectional study, patients referred to catheterization laboratory for clinically indicated coronary angiography were prospectively screened for angiographically intermediate stenosis (50-80%). Seventy lesions from 60 patients were evaluated. Mean angiographic stenosis was 62.1 ± 16.3%. After having performed FFR assessment, intravascular ultrasound (IVUS) was performed over the FFR wire. Virtual histology IVUS was used to identify the plaque components and thin cap fibroatheroma (TCFA). TCFA was significantly more frequent (65 vs. 38%, p = 0.026), and necrotic core volume (26.15 ± 14.22 vs. 16.21 ± 8.93 mm3, p = 0.04) was significantly larger in the positively remodeled than non-remodeled vessels. Remodeling index correlated with necrotic core volume (r = 0.396, p = 0.001) and with FFR (r = -0. 419, p = 0.001). With respect to plaque components, only necrotic core area (r = -0.262, p = 0.038) and necrotic core volume (r = -0.272, p = 0.024) were independently associated with FFR. In the multivariable model, presence of TCFA was independently associated with significantly lower mean FFR value as compared to absence of TCFA (adjusted, 0.71 vs. 0.78, p = 0.034). Conclusion: The current study demonstrated that for a given stenosis geometry, features of plaque vulnerability such as necrotic core volume, TCFA, and positive remodeling may influence the hemodynamic relevance of intermediate coronary stenoses.

Low vitamin D levels predict left atrial thrombus in nonvalvular atrial fibrillation.

BACKGROUND AND AIMS: We determined the association between left atrial (LA) thrombus occurrence and a non-classic risk marker, plasma levels of vitamin D, in atrial fibrillation (AF) patients on continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy for ≥4 weeks. Low levels of plasma 25-hydroxy vitamin D (25-OHD) are predictive of fatal stroke. Vitamin D has anticoagulant effects on the coagulation cascade, which are indirectly targeted by NOAC therapy. The impact of plasma levels of vitamin D on the rate of LA thrombus detected by transesophageal echocardiography (TEE) in AF patients is unknown. METHODS AND RESULTS: We enrolled 201 (133 female) AF patients who were using continuous NOAC therapy for ≥4 weeks. All patients underwent transthoracic and TEE examination. Serum concentrations of 25-OHD, C-reactive protein (CRP) levels, CHA2DS2-VASc scores and parameters, LA size, and left ventricle ejection fraction (LVEF) were examined before the TEE procedure. LA thrombus occurrence was independently associated with serum levels of 25-OHD (OR: 0.884; 95% CI: 0.839-0.932; P < 0.001), LA diameter (OR: 1.120; 95% CI: 1.038-1.209; P = 0.003), and LVEF(OR: 0.944; 95% CI: 0.896-0.995; P = 0.032). Dense spontaneous echo contrast (SEC) presence was also inversely associated with 25-OHD concentrations. CONCLUSIONS: Low 25-OHD levels, as a non-classic risk factor, were independently and significantly associated with dense SEC and LA thrombus occurrence in AF patients under NOAC therapy, as well as LA enlargement and decreased LVEF. Further large-scale studies are needed to explain the role of vitamin D deficiency, or efficacy of replacement, on LA thrombus occurrence.

Comparison of clinical characteristics of patients with heart failure and preserved ejection fraction with atrial fibrillation versus sinus rhythm: Insights from the APOLLON registry.

OBJECTIVE: The aim of this study was to assess the clinical characteristics of patients with heart failure and preserved ejection fraction (HFpEF) and atrial fibrillation (AF) and compare them with those of HFpEF patients without AF. METHODS: This study was a sub-group analysis of a multicenter, observational, and cross-sectional registry conducted in Turkey (ClinicalTrials.gov identifier: NCT03026114). Patients with HFpEF were divided into 2 groups: HFpEF with AF and HFpEF with sinus rhythm (SR), and the clinical characteristics of the groups were compared. RESULTS: In a total of 819 HFpEF patients (median age: 67 years; 58% women), 313 (38.2%) had AF. Compared to the patients with SR, those with AF were older (70 years vs 66 years; p<0.001) and more symptomatic, with a higher rate of classification as New York Heart Association functional class III-IV, paroxysmal nocturnal dyspnea, orthopnea, palpitations, fatigue, pulmonary crepitations, and peripheral edema. The hospitalization rate for heart failure was higher (28.4% vs 12.6%; p<0.001) in patients with AF, and participants with AF had higher level of N-terminal pro-B-type natriuretic peptide (887 pg/mL vs 394.8 pg/mL; p<0.001) and higher left atrial volume index level. Patients without AF had a higher burden of diabetes mellitus, obstructive sleep apnea, and coronary artery disease. The prescription rate of nondihydropyridine calcium blockers, digoxin, loop diuretics, and anticoagulant drugs was higher in the AF group. CONCLUSION: The results of this study revealed that in a large Turkish cohort with HFpEF, significant clinical differences were present between those with and without AF and. Further prospective studies are needed to clarify the prognostic implications of AF in this growing heart failure population in our country.

Gender disparities in heart failure with mid-range and preserved ejection fraction: Results from APOLLON study.

OBJECTIVE: This study aimed to examine gender-based differences in epidemiology, clinical characteristics, and management of consecutive patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF). METHODS: The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is a multicenter, cross-sectional, and observational study. Consecutive patients with HFmrEF or HFpEF who were admitted to the cardiology clinics were included (NCT03026114). Herein, we performed a post-hoc analysis of data from the APOLLON trial. RESULTS: The study population included 1065 (mean age of 67.1+-10.6 years, 54% women) patients from 11 sites in Turkey. Compared with men, women were older (68 years vs. 67 years, p<0.001), had higher body mass index (29 kg/m2 vs. 27 kg/m2, p<0.001), and had higher heart rate (80 bpm vs. 77.5 bpm, p<0.001). Women were more likely to have HFpEF (82% vs. 70.9%, p<0.001), and they differ from men having a higher prevalence of hypertension (78.7% vs. 73.2%, p=0.035) and atrial fibrillation (40.7% vs. 29.9%, p<0.001) but lower prevalence of coronary artery disease (29.5% vs. 54.9%, p<0.001). Women had higher N-terminal pro-B-type natriuretic peptide (691 pg/mL vs. 541 pg/mL, p=0.004), lower hemoglobin (12.7 g/dL vs. 13.8 g/dL, p<0.001), and serum ferritin (51 ng/mL vs. 64 ng/mL, p=0.001) levels, and they had worse diastolic function (E/e'=10 vs. 9, p<0.001). The main cause of heart failure (HF) in women was atrial fibrillation, while it was ischemic heart disease in men. CONCLUSION: Clinical characteristics, laboratory findings, and etiological factors are significantly different in female and male patients with HFmrEF and HFpEF. This study offers a broad perspective for increased awareness about this patient profile in Turkey.

Influence of coronary calcification patterns on hemodynamic outcome of coronary stenoses and remodeling.

OBJECTIVE: The histological characteristics of plaque may affect the hemodynamic outcome of a given coronary stenosis. In particular, the potential effect of volumetric calcium content and the topographical distribution in the lesion segment on physiological outcome has not yet been investigated. The aim of this study was to identify any potential correlation between patterns of calcification and the fractional flow reserve (FFR) and the coronary remodeling index (RMI). METHODS: A total of 26 stable angina pectoris and 34 acute coronary syndrome patients without persistent ST-segment elevation constituted the study population. FFR was used to assess 70 intermediate coronary stenosis lesions. After obtaining hemodynamic measurements, quantitative grayscale and virtual histology-intravascular ultrasound analyses were performed. The depth, length, and circumferential distribution of calcification of the lesions were also recorded. RESULTS: Within the analyzed segment (area of interest, lesion segment), FFR was correlated with maximal thickness of deep calcification (r=-0.285; p=0.021) and calcification angle (r=-0.396; p=0.001). In lesions with a calcification angle >180°, the mean FFR value was significantly lower compared with those <180° (0.64±0.17 vs. 0.78±0.08; p=0.024). RMI was correlated with maximal angle of superficial (r=-0.437; p<0.001) and deep (r=0.425; p<0.001) calcification. RMI was correlated with maximal thickness of superficial (r=-0.357; p=0.003) and deep (r=0.417; p<0.001) calcification. RMI was also correlated with FFR (r=-0.477; p<0.001). CONCLUSION: This study demonstrated that the geometry, location, and amount of calcification of a plaque could affect hemodynamic and anatomical outcome measures in functionally significant stenoses by affecting vessel wall compliance.

Effects of sleep bruxism related tinnitus on quality of life.

OBJECTIVES: This study aims to analyze the subjective and objective characteristics of tinnitus in sleep bruxism patients. PATIENTS AND METHODS: The study included 57 patients (12 males; 45 females; mean age 33.89±12.50 years; range 19 to 55 years) with sleep bruxism and tinnitus (sleep bruxism group) and 24 patients (6 males, 18 females; mean age 43.75±16.19 years; range 21 to 58 years) only with tinnitus (control group). Sleep bruxism was diagnosed by the diagnostic criteria of American Academy of Sleep Medicine. Patients were performed pure tone audiometry to detect hearing thresholds at standard and high frequencies. Tinnitus frequency and loudness were assessed. Subjective aspects of tinnitus were identified by tinnitus handicap inventory. RESULTS: The statistical analysis revealed that the sleep bruxism group had significantly lower hearing thresholds except 1000 Hz and 2000 Hz. Tinnitus frequency was between 3000 Hz and 18000 Hz in sleep bruxism group while it was between 6000 and 16000 Hz in control group with no statistically significant difference (p=0.362). Sleep bruxism group had significantly lower tinnitus loudness and tinnitus handicap inventory scores in comparison to control group (p=0.024 and p=0.000, respectively). CONCLUSION: Tinnitus caused by sleep bruxism and temporomandibular joint issues has higher frequency and lower loudness compared to patients with only tinnitus.

Potential contribution of virtual histology plaque composition to hemodynamic-morphologic dissociation in patients with non-ST elevation acute coronary syndrome.

OBJECTIVE: Histologic plaque characteristics may influence the hemodynamic effect generated by physiologically significant unstable coronary lesions where plaque content and surface related factors are expected to contribute to the maximum translesional pressure drop. In this study, we aimed to identify local lesion specific virtual histological characteristics that may potentially affect hemodynamic outcome measures. METHODS: Forty-eight consecutive patients with non-ST-elevation acute coronary syndrome (NSTEACS) having paired hemodynamic and morphological data were enrolled. A dual sensor guide-wire was used for the assessment of fractional flow reserve (FFR) and stenosis resistance (HSR) in the culprit vessel. Virtual histology intravascular ultrasound imaging was performed after obtaining hemodynamic data. RESULTS: In a hemodynamically significant lesion subset (FFR<0.75 [n=34]), after controlling for lesion length, MLA and coronary artery compliance, FFR correlated with necrotic core (NC) area (r=-0.423, p=0.028) at MLA and NC volume (r=-0.497, p=0.008) and dense calcium (DC) volume (r=-0.332, p=0.03) across the entire lesion segment. Likewise, NC (r=-0.544, p=0.005) and DC (r=0.376, p=0.03) areas at MLA and NC (r=0.545, p=0.005) and DC (r=0.576, p=0.003) volumes across the entire lesion segment were associated with HSR in the hemodynamically significant lesion group (HSR>0.80 [n=33]). However, no correlation has been observed between intracoronary hemodynamic end-points and plaque components in hemodynamically insignificant lesions. CONCLUSIONS: This study demonstrated that for a given coronary stenosis geometry and arterial compliance, plaque composition may influence hemodynamic outcome measures in functionally significant stenoses in patients with NSTEACS.

Subjective and Objective Effects of Androgen Ablation Therapy on Voice.

OBJECTIVES: The aim of present study was to evaluate possible side effects of androgen deprivation therapy (ADT) on voice quality by means of objective and subjective measures. STUDY DESIGN: Cross-sectional. METHODS: Thirty-five male patients who had been diagnosed with prostate cancer and who had been using bicalutamide and goserelin acetate combination for at least 12 months were included in the study. Thirty healthy nonsmoker males of similar age and without any laryngeal pathology constituted the control group. Acoustic and aerodynamic voice analyses and voice handicap index-10 were applied to both groups. Maximum phonation time, fundamental frequency, jitter, shimmer, and noise-to-harmonic ratio were determined during acoustic and aerodynamic voice analyses. RESULTS: Maximum phonation times were 18.86 ± 5.24 and 24.20 ± 3.59 in ADT and control groups, respectively. It was significantly higher in the control group. Fundamental frequencies were 143.73 ± 18.47 and 135.00 ± 13.18 in ADT and control groups, respectively. Jitter values were 2.72 ± 0.62 and 1.99 ± 0.27 in ADT and control groups, respectively. Shimmer values were 11.50 ± 1.81 and 10.48 ± 1.36 in ADT and control groups, respectively. Fundamental frequency, jitter, and shimmer values were significantly higher in the ADT group. Noise-to-harmonic ratio values did not differ between groups. Voice handicap index-10 result was significantly higher in the ADT group. CONCLUSIONS: ADT has adverse effects on the human voice. Prospective studies with long-term follow-up of a larger cohort are required for more detailed analysis.

Comparison of two partial middle turbinectomy techniques for the treatment of a concha bullosa.

OBJECTIVES/HYPOTHESIS: To assess the nasal functions, nasal resistance, and olfactory function in middle turbinate surgery. STUDY DESIGN: Randomized controlled trial. METHODS: This prospective controlled study was carried out on patients who underwent laminectomy for aeration of the middle turbinate. Patients participating in the study were divided into two groups-group 1: medial laminectomy (n = 34) and group 2: lateral laminectomy (n = 38). Patients underwent the preoperative visual analogue score, sinonasal outcome test-22 (SNOT-22), peak nasal inspiratory flowmeter, and Connecticut Chemosensory Clinical Research Center smell test. All patients were reevaluated 3 months after the operation. RESULTS: The study group comprised 72 consecutive patients. The mean age of the patients was 31.03 ± 9.7, with a range of 17 to 54 years. A total of 47.2 % (n = 34) had medial and 52.8% (n = 38) had lateral laminectomy. Bilateral turbinate intervention was performed in 27.8% (n = 20), whereas unilateral middle turbinate intervention was performed in 72.3% (n = 52). Overall, both groups showed strong significant improvement over time in visual analogue scale results, SNOT-22 scores, peak flowmeter results, and olfactory function between preoperative and postoperative scores (P < 0.001). There was no significant difference between the groups for all parameters (P > 0.05). CONCLUSIONS: This study revealed that medial laminectomy for aeration of the middle turbinate was as effective as lateral laminectomy. LEVEL OF EVIDENCE: 1b. Laryngoscope, 125:1062-1066, 2015.

Evaluation of voice quality after supraglottic laryngectomy.

OBJECTIVE: Supraglottic laryngectomy is a surgical procedure that preserves laryngeal functions. This technique allows extensions including removal of tongue base or 1 arytenoid. We aimed to compare vocal results of supraglottic laryngectomy and extended procedures. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Thirty-three males who underwent supraglottic laryngectomy were included in the study. Fifteen patients (45.5%) were applied standard supraglottic laryngectomy (standard supraglottic laryngectomy group). In 11 patients (33.3%), unilateral arytenoid cartilage was totally resected by separation at the cricoarytenoid joint (laterally extended group), and the tongue base was removed in 7 patients (anteriorly extended group) (21.2%). Twenty male smokers constituted control group. Acoustic and aerodynamic voice analyses were performed for the assessment of objective results. Grade, roughness, breathiness, asthenia, and strain scale (GRBAS) scores were analyzed for perceptual assessment. Voice Handicap Index-30 was used to evaluate subjective results. RESULTS: The comparison of supraglottic laryngectomy group with the control group revealed that the mean maximum phonation time and fundamental frequency were significantly lower in the supraglottic laryngectomy group (P < .001), and the mean jitter, shimmer, and noise-to-harmonics ratio were significantly higher in the supraglottic laryngectomy group (P < .001). Maximum phonation time and fundamental frequency were higher in the standard supraglottic laryngectomy group in comparison to extended groups. Jitter value was also lower in the standard supraglottic laryngectomy group compared to extended groups. Perceptual and subjective analyses revealed no difference among standard supraglottic laryngectomy and extended groups. CONCLUSION: The results of this study indicate that supraglottic laryngectomy patients have acceptable voice quality, as determined by perceptual and subjective assessment.