Predictive Value of the Prognostic Nutritional Index for Long-Term Mortality in Patients with Advanced Heart Failure.

Background: Malnutrition is common in patients with advanced heart failure (HF), and both conditions have a poor prognosis. Objectives: We sought to determine the predictive value of nutritional status using the prognostic nutritional index (PNI) for long-term mortality in patients with advanced HF. Methods: This is a retrospective observational study. The optimal PNI cut-off value for predicting all-cause mortality was determined to be 50.5 using receiver operating characteristic curve analysis. Patients were divided into two groups: the low PNI (≤ 50.5) and high PNI (> 50.5) group. Results: A total of 217 patients (age 48.9 ± 9.9 years, 82.5% male) with advanced HF were included in this study. The mean follow-up duration was 28.6 ± 19.4 months. The high PNI group had higher 5-year all-cause and cardiovascular death-free survival rates compared to the low PNI group (86.7% vs. 24.6%, log-rank p < 0.001) and (89.6% vs. 36.1%, log-rank p < 0.001), respectively. In multivariable Cox regression analyses, low PNI [hazard ratio (HR): 4.70; 95% confidence interval (CI): 2.19-10.11, p < 0.001] and high sensitivity C-reactive protein (hsCRP) (HR: 1.02; 95% CI: 1.01-1.03, p = 0.04) were found to be independent predictors of long-term all-cause mortality. Low PNI (HR: 4.52; 95% CI: 1.99-10.24, p < 0.001), hsCRP (HR: 1.01; 95% CI: 1.00-1.03, p = 0.04), and New York Heart Association class IV vs. III (HR: 2.56; 95% CI: 1.36-4.82, p = 0.03) were also found to be independent predictors of long-term cardiovascular mortality. Conclusions: PNI was found to be an independent predictor of long-term all-cause and cardiovascular mortality in patients with advanced HF, and it can be used as an objective and simple tool for risk stratification.

Determination of Factors Affecting Time in Therapeutic Range in Patients on Warfarin Therapy.

BACKGROUND: The effectiveness and safety of warfarin depend on maintaining an international normalized ratio (INR) within the therapeutic range. Time in Therapeutic Range (TTR) is defined as the percentage of time a patient's INR is within the therapeutic range. OBJECTIVE: We sought to determine the factors affecting good TTR in patients on warfarin therapy. METHODS: This was a descriptive cross-sectional study conducted in a single tertiary care center. Good anticoagulation control was defined as TTR ≥65%. RESULTS: The study population consisted of 518 patients. The mean age was 57.6 ± 12.3 (19-87) and 54.4% of the patients were female. 47.5% patients achieved good anticoagulation control (TTR ≥65%). The mean Medication Adherence Report Scale (MARS) score was significantly higher in patients with good TTR (23.5 ± 1.9 vs. 22.8 ± 2.1, p = .002). Only 40.2% of the patients received education on warfarin. In multivariable analyses, the duration of warfarin therapy >10 years (OR: 2.27, 95% CI: 1.34-3.84, p = .002) and MARS score (OR: 1.22, 95% CI: 1.09-1.35, p < .001) were found to be the independent predictors of the good anticoagulation control. CONCLUSION: Duration of warfarin therapy >10 years and MARS score were the independent predictors of good anticoagulation control.

Which One to Treat When Pannus and Thrombus Coexist in a Mechanical Aortic Valve?: An Equivocal Case.

The coexistence of pannus and thrombus is not uncommon. Accurate diagnosis of the etiology of prosthetic valve dysfunction (PVD) is of utmost importance in guiding adequate and rational therapy. We present a case of PVD in which computed tomography played a decisive role in guiding treatment. (Level of Difficulty: Intermediate.).

An overlooked cause for reversible severe tricuspid regurgitation and pulmonary hypertension: Hibernating right ventricle.

Tricuspid regurgitation (TR) can occur due to many etiologies, including primary valve disease, left heart disease, annular dilatation in atrial fibrillation, or pulmonary hypertension (PH). Functional TR is caused by tricuspid annular dilatation in the setting of right ventricular remodeling. The right ventricle (RV) ischemia is an overlooked cause of functional TR which tends to diminish with an improvement in right heart functions. We present the case of a patient in whom functional TR significantly improved after percutaneous revascularization. We highlight that the ischemic RV can present with reversible functional TR or PH and emphasized the necessity of accurate detection of the etiology.

Left ventricular assist device implantation combined with bentall procedure

Abstract Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Left Ventricular Assist Device Implantation Combined with Bentall Procedure.

Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Red cell distribution width and end-organ damage in patients with systo-diastolic hypertension.

INTRODUCTION: Both end-organ damage and high red cell distribution width (RDW) values are associated with adverse cardiovascular events, inflammatory status, and neurohumoral activation in hypertensive disease and in the general population. In this study, we investigated the relationship between RDW and end-organ damage in hypertensive patients. MATERIAL AND METHODS: The 446 systo-diastolic hypertensive patients included in the study received 24-hour ambulatory blood pressure monitoring. Left ventricular mass index, glomerular filtration rate, and microalbuminuria were measured to identify end-organ damage. High-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels of all patients were also examined. RESULTS: The mean age of the participants was 49.96 ±11.04 years. The mean RDW was 13.06 ±1.05%. Red cell distribution width was positively correlated with left ventricular myocardial index (LVMI), urinary albumin, hs-CRP, and NT-proBNP (r = 0.298, p < 0.001; r = 0.228, p < 0.001; r = 0.337, p < 0.001; r = 0.277, p < 0.001, respectively), while RDW was negatively correlated with eGFR (r = -0.153, p < 0.001). Additionally, while there was a positive correlation between RDW and 24-h systolic blood pressure, no correlation was found between RDW and 24-h diastolic blood pressure (r = 0.132, p = 0.006 and r = 0.017, p = 0.725, respectively). Multiple linear regression analysis revealed that RDW levels were independently associated with eGFR, LVMI, and severity of albuminuria (ß = 0.126, p = 0.010; ß = -0.149, p = 0.002; ß = 0.114, p = 0.035). CONCLUSIONS: High RDW levels in systo-diastolic hypertensive patients were found to be an independent predictor of end-organ damage.

Predictive value of a fragmented QRS complex in patients undergoing primary angioplasty for ST elevation myocardial infarction.

OBJECTIVES: The aim of this study was to evaluate the prognostic value of fragmented QRS (fQRS) on electrocardiography (ECG) patients with acute ST-segment elevation in myocardial infarction (STEMI), who are undergoing primary percutaneous coronary intervention (PCI). METHODS: We prospectively enrolled 414 consecutive STEMI patients (mean age of 55.2 ± 12.2 years old, range of 26-91-years old) undergoing primary PCI. The study patients were divided into two groups according to the presence or absence of fQRS as shown by ECG in the first 48 hours. The presence of fQRS group was defined as fQRS(+) (n = 91), and the absence of fQRS group was defined as the fQRS(-) (n = 323) group. Clinical characteristics and the one-year outcome of the primary PCI were analyzed. RESULTS: The patients in the fQRS(+) group were older (mean age 60.7 ± 12.5 vs. 53.6 ± 11.6 years old, P < 0.001). Higher one-year all-cause mortality rates were observed in the fQRS group upon ECG (23.1% vs. 2.5%, P < 0.001, respectively). When using the Cox multivariate analysis, the presence of fQRS on the ECG was found to be a powerful independent predictor of one-year all-cause mortality (hazard ratio: 5.24, 95% confidence interval: 1.43-19.2, P = 0.01). CONCLUSIONS: These results suggest that the presence of fQRS on ECG was associated with an increased in-hospital cardiovascular mortality, and one-year all-cause mortality in patients with STEMI who are under primary PCI.

Effects of percutaneous closure of atrial septal defect on left atrial mechanical and conduction functions.

AIMS: Atrial septal defect (ASD) is one of the most common congenital heart diseases in adults. We prospectively evaluated early and mid-term effects of the percutaneous closure of secundum ASD on atrial electromechanical delay (AEMD) and left atrial (LA) mechanical functions at the first day and sixth month in patients undergoing percutaneous closure. METHODS AND RESULTS: Forty-one patients were included in this study. Twenty-six (63.4%) of the 41 patients were female and the mean age was 41 ± 13 years. All the patients had echocardiographic examination before the procedure and at the first day and sixth month after the procedure. LA volumes (maximal, minimal, and presystolic) and EMD (lateral, septal, and tricuspid) were measured. Left and right intra- and inter-AEMD were not changed at the first day but both were significantly shorter at the sixth month. There was no change in the total emptying volume and fraction before and after the procedure. LA maximal, minimal, and pre-systolic volumes, active emptying volume, and fractions were decreased at the first day and at the sixth month compared with pre-procedural volumes. LA passive emptying volume, passive emptying fraction, and conduit volume were increased at the first day and at the sixth month compared with pre-procedural volumes. CONCLUSION: Our results revealed that there was no change in the LA mechanical reservoir functions, but improved conduit function and impaired contractility functions early and in the mid-term after percutaneous closure of ASD and decreased AEMD only in the mid-term.

Predictive Value of Elevated Uric Acid in Turkish Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction.

BACKGROUND: Uric acid (UA) is an independent risk factor for the development of coronary heart disease. Serum UA levels have been correlated with all major forms of death from cardiovascular disease, including acute, subacute, and chronic forms of coronary artery disease (CAD), heart failure, and stroke. However, its value in acute ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of this study was to evaluate the prognostic value of UA in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: We prospectively enrolled 434 consecutive Turkish STEMI patients (mean age 55.4 ± 12.4 years, 341 male, 93 female) undergoing primary PCI. The study population was divided into tertiles based on admission UA values. The high UA group (n = 143) was defined as a value in the third tertile (> 5.7 mg/dl), and the low UA group (n = 291) included those patients with a value in the lower two tertiles (≤ 5.7 mg/dl). Clinical characteristics, in-hospital and six-month outcomes of primary PCI were analyzed. RESULTS: Compared to the low UA group, only Killip class > 1 at admission was more prevalent in the high UA group (3.4% vs. 17.5%, p < 0.001, respectively). Higher in-hospital cardiovascular mortality and six-month all-cause mortality rates were observed in the high UA group than in the lower group (12.6% vs. 1.7%, respectively, p < 0.001) and (19.6% vs. 4.1%, respectively, p < 0.001). In Cox multivariate analysis; a high admission UA value (> 5.7 mg/dl) was found to be a powerful independent predictor of six-month all-cause mortality (hazard ratio: 5.57, 95% confidence interval: 1.903-16.3, p = 0.002). CONCLUSIONS: These results suggest that a high level of UA on admission was associated with increased in-hospital cardiovascular mortality, and six-month all-cause mortality in Turkish patients with STEMI undergoing primary PCI. KEY WORDS: Primary angioplasty; ST elevation myocardial infarction; Uric acid.

Prognostic value of elevated mean platelet volume in patients undergoing primary angioplasty for ST-elevation myocardial infarction.

OBJECTIVE: The aim of this study was to evaluate the prognostic value of mean platelet volume (MPV) in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: We prospectively enrolled 495 consecutive STEMI patients.The study population was divided into tertiles based on admission MPV values. The high MPV group (n= 148) was defined as a value in the third tertile (> 8.9), and the low MPV group (n = 347) included those patients with a value in the lower two tertiles (< or = 8.9). Clinical characteristics, in-hospital and six-month outcomes of primary PCI were analysed. RESULTS: Higher six-month all-cause mortality rates were observed in the high MPV group In Cox multivariate analysis; a high admission MPV value (> 8.9) was found to be a powerful independent predictor of six-month all-cause mortality. CONCLUSIONS: These results suggest that a high admission MPV level was associated with increased six-month all-cause mortality in patients with STEMI undergoing primary PCI.

Electrophysiological evaluation of atrioventricular conduction disturbances in transcatheter aortic valve implantation with Edwards SAPIEN prosthesis.

AIMS: Permanent pacemaker requirement is a known complication after transcatheter aortic valve implantation (TAVI). The aim of the present study was to analyze the effects of Edwards SAPIEN prosthesis implantation on atrioventricular conduction. METHODS: The study included 28 patients who underwent TAVI due to severe aortic valve stenosis. An electrophysiological study was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after Edwards SAPIEN prosthesis implantation. RESULTS: His-ventricle interval was significantly prolonged postprocedure (55.9 ± 11.5 ms) vs preprocedure (47.3 ± 7.8 ms) (P<.001). The antegrade Wenckebach point was observed to be significantly prolonged postprocedure (354.4 ± 41.3 ms) vs preprocedure (333.7 ± 45.4 ms) (P=.001). Despite atrial-His interval prolongation, it was not statistically significant. After the procedure, we observed significant conduction disturbances in 3 patients (10.7%). These conduction problems recovered before discharge. One of the patients (3.6%) with right bundle branch block + left anterior fascicular block required permanent pacemaker implantation. At postprocedure electrocardiogram, QRS duration increased, QRS axis shifted to the left, and both of the values became normal before discharge. The patient's echocardiographic and clinical parameters were improved during follow-up. CONCLUSION: The effect of Edwards SAPIEN on the conduction system was mostly infranodal and temporary. The physical properties of the Edwards SAPIEN prosthesis may explain this observation. This complication may be lessened if the frame height characteristics can be improved.

Predictive value of elevated cystatin C in patients undergoing primary angioplasty for ST-elevation myocardial infarction.

OBJECTIVES: The prognostic value of cystatin C (CysC) has been documented in patients with acute coronary syndrome without ST-segment elevation. However, its value in acute ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of this study was to evaluate the prognostic value of CysC in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: We prospectively enrolled 475 consecutive STEMI patients (mean age 55.6±12.4 years, 380 male, 95 female) undergoing primary PCI. The study population was divided into tertiles based on admission CysC values. The high CysC group (n=159) was defined as a value in the third tertile (>1.12 mg/L), and the low CysC group (n=316) included those patients with a value in the lower two tertiles (≤1.12 mg/L). Clinical characteristics and in-hospital and one-month outcomes of primary PCI were analyzed. RESULTS: The patients of the high CysC group were older (mean age 62.8±13.1 vs. 52.3±10.5, P<.001). Higher in-hospital and 1-month cardiovascular mortality rates were observed in the high CysC group (9.4% vs. 1.6%, P<.001 and 14.5% vs. 2.2%, P<.001, respectively). In Cox multivariate analysis; a high admission CysC value (>1.12 mg/L) was found to be a powerful independent predictor of one-month cardiovascular mortality (odds ratio, 5.3; 95% confidence interval, 1.25-22.38; P=.02). CONCLUSIONS: These results suggest that a high admission CysC level was associated with increased in-hospital and one-month cardiovascular mortality in patients with STEMI undergoing primary PCI.

Predictive value of elevated D-dimer in patients undergoing primary angioplasty for ST elevation myocardial infarction.

The aim of this study was to evaluate the prognostic value of D-dimer in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). The prognostic value of D-dimer has been documented in patients with acute coronary syndrome without ST-segment elevation. However, its value in acute ST-segment elevation myocardial infarction (STEMI) remains unclear. We prospectively enrolled 453 consecutive STEMI patients (mean age 55.6 ± 12.4 years, 364 male, 89 female) undergoing primary PCI. The study population was divided into tertiles based on admission D-dimer values. The high D-dimer group (n = 151) was defined as a value in the third tertile [>0.72 ug/ml fibrinogen equivalent units (FEU)], and the low D-dimer group (n = 302) included those patients with a value in the lower two tertiles (≤0.72 ug/ml FEU). Clinical characteristics, in-hospital and 6-month outcomes of primary PCI were analyzed. The patients of the high D-dimer group were older (mean age 60.1 ± 13.5 versus 52.4 ± 10.6, P < 0.001). Higher in-hospital cardiovascular mortality and 6-month all-cause mortality rates were observed in the high D-dimer group (7.2 versus 0.6%, P < 0.001 and 13.9 versus 2%, P < 0.001, respectively). In Cox multivariate analysis; a high admission D-dimer value (>0.72 ug/ml FEU) was found to be a powerful independent predictor of 6-month all-cause mortality (odds ratio: 10.1, 95% confidence interval: 1.24-42.73, P = 0.03). These results suggest that a high admission D-dimer, level was associated with increased in-hospital cardiovascular mortality and 6-month all-cause mortality in patients with STEMI undergoing primary PCI.

Prognostic value of total bilirubin in patients with ST-segment elevation acute myocardial infarction undergoing primary coronary intervention.

Previous studies have shown that the serum total bilirubin (TB) concentration was inversely related with stable coronary artery disease, diabetes mellitus, hypertension, and metabolic syndromes. The relation between TB levels and in-hospital and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is not known. Data from 1,624 consecutive patients with STEMI who underwent primary PCI were evaluated. TB was measured after primary PCI, and the study population was divided into tertiles. The high TB group (n = 450) was defined as a value in the upper third tertile (>0.9 mg/dl) and the low TB group (n = 1,174) as any value in the lower 2 tertiles (≤0.9 mg/dl). The in-hospital mortality rate was significantly greater in the high TB group than in the low TB group (4% vs 1.5%, p = 0.003). In the multivariate analyses, a significant association was noted between high TB levels and the adjusted risk of in-hospital cardiovascular mortality (odds ratio 3.24, 95% confidence interval 1.27 to 8.27, p = 0.014). In the receiver operating characteristic curve analysis, TB >0.90 mg/dl was identified as an effective cutpoint in patients with STEMI for in-hospital cardiovascular mortality (area under the curve 0.66, 95% confidence interval 0.55 to 0.76, p = 0.001). The mean follow-up period was 26.2 months. No differences were seen in the long-term mortality rates between the 2 groups. In conclusion, high TB is independently associated with in-hospital adverse outcomes in patients with STEMI who undergo primary PCI. However, no association was found with long-term mortality.

Prognostic significance of tumor volume in nasopharyngeal carcinoma.

OBJECTIVE: To investigate the prognostic significance of primary and residual tumor volume in nasopharyngeal carcinoma. METHODS: 56 patients were included in the study. Diameters of tumors were measured from CT and MR film hardcopies. Diameter-based measurements were computed as an ellipsoid (V=4/3·π·d1·d2·d3) to calculate diameter-based volume. It was investigated whether primary tumor volume provided prognostic information about local regional recurrence free survival (LRRFS), disease free survival (DFS), distant metastasis free survival (DMFS) and overall survival (OS) by monovariant and multivariant analysis. Kaplan-Meier survival analysis method and log-rank test were used to estimate survival analysis (95% confidence interval). Cox regression test was used for two variant and multivariant survival analysis. Statistical Package for Social Sciences (SSSP) 10.0 for Windows programme was used for data analysis. RESULTS: In the multivariate analysis, in the patients with tumor volume more than 60ml, local regional recurrence more frequently developed. The relationship between tumor volume and local regional recurrence was found significant (p=0.053). In the monovariate analysis, primary tumor volume was found to be a significant predictive value on DFS and DMFS. In the patients with tumor volume below 20ml, DFS was 60%, whereas in the patients with tumor volume above 60ml, DFS was 0% (p=0.007). The prevalence were 68% and 0% in the patients group that had tumor volume below 30ml and above 60ml respectively. DMSF ratios in the patients with primary tumor volume below 20ml and above 60ml were 86.67% and 33.3% respectively. The residual tumor volume (RTV) at first control after treatment was found to be a significant prognostic factor on LRRFS (p=0.03). CONCLUSION: The foundation of new T staging systems that consists of PTV that was found as an independent prognostic factor alone in multivariate statistical analysis may precede better prediction of prognosis and more appropriate treatment of patients having different prognostic factors. RTV in the first control after treatment was a significant prognostic factor on LRRFS.

Serum lactate dehydrogenase level is a prognostic factor in patients with locoregionally advanced nasopharyngeal carcinoma treated with chemoradiotherapy.

We investigated the treatment results and probable prognostic factors in patients with locoregionally advanced nasopharyngeal carcinoma (NPC) treated with neoadjuvant chemotherapy (NCT) plus conventional radiotherapy (RT) or concomitant chemoradiotherapy (CCRT) at our hospital. We retrospectively evaluated 61 patients (48 males, 13 females) with locoregionally advanced NPC treated either with 2 cycles of NCT plus RT (Group A, 37 patients) or with three cycles of NCT plus CCRT (Group B, 24 patients) between September 1995 and October 2002. According to the AJCC 1997 classification system, 19 patients had Stage III disease and 42 had Stage IV. NCT consisted of cisplatin and 5-fluorouracil. Total RT doses were ranged between 59.4-71.6 Gy (median: 66.2 Gy). Concomitant cisplatin (75 mg/m(2)) was given on first days of Weeks 1, 4, 7 of CCRT. Patient sex, histopathologic subtype, T status, ECOG performance status, stage, serum lactate dehydrogenase (LDH) level, and cranial nerve involvement at diagnosis were comparable in the 2 groups. There were statistically significant differences between median follow-up times and N status for the 2 groups. Fifty-five (90.2 percent) patients completed all planned NCT. Univariate analysis revealed the pretreatment LDH level as the only statistically significant prognostic factor for disease-free survival (DFS) and overall survival (OS). Four-year DFS rates were 55.9 percent and 21.3 percent for patients with normal and high serum LDH levels, respectively (P = 0.04). Four-year OS rates were 68.7 percent and 28.5 percent for patients with normal and high serum LDH levels, respectively (P = 0.01). Multivariate analysis also revealed that high serum LDH level was the only independent risk factor that predicted OS. The relative risk was 2.43 (95%CI: 1.08-5.45) for patients with high serum LDH levels (P = 0.03). No independent risk factors associated with DFS were found for other prognosticators. Our study demonstrated that high serum LDH level is the only independent unfavorable risk factor for OS in patients with locoregionally advanced NPC who were treated with NCT plus RT or CCRT.