Do the Different Types of Pulmonary Hypertension Cause the Same Effect on Right Heart and Serum Asymmetrical Dimethylarginine Levels in Female Patients?

ABSTRACT Objective: Right-heart function is a major determinant of clinical outcome in patients with elevated pulmonary artery pressure due to pulmonary venous hypertension (PVH) and pulmonary arterial hypertension (PAH). Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase. This study aimed to evaluate if different types of pulmonary hypertension (PH) would cause the same effect on right-heart functions and serum ADMA levels in female patients. Methods: This study included patients with PAH as group I, patients with PVH due to mitral stenosis (mitral valve area ≤ 1.5 cm2, without any additional valve or left-heart disease and systolic pulmonary artery pressure ≥ 50 mmHg in transthoracic echocardiography) as group II, and healthy control subjects as group III. Transthorasic echocardiographic evaluations for right-heart functions were performed according to the guidelines of the American Society of Echocardiography. Venous blood samples were collected, and the serum ADMA concentrations were obtained with the ELISA kit (DRG® International Inc., Springfield, NJ, USA). Results: Patients in groups I and II had higher ADMA levels than healthy control subjects. Right-atrium area and dimensions, right-ventricular (RV) volumes, grade of tricuspid regurgitation, systolic pulmonary arterial pressure, RV wall thickness, and RV outflow tract diameters were significantly higher in group I patients than in group II patients. Right-ventricular myocardial performance index was lower, and RV fractional area change and tricuspid valve systolic tissue Doppler velocity were higher in group II patients than in group I patients. Conclusion: This study demonstrated that both PAH and PVH caused increase in right-heart dimensions and impairment in right-heart functions.

Long-term vitamin-K antagonist use and coronary artery calcification.

BACKGROUND: The aim of this study was to investigate the impact of vitamin K antagonist (VKA) therapy on coronary artery calcification (CAC) by comparing long-term VKA users with metallic prosthetic valves (MPVs) and VKA-free patients undergoing coronary calcium scoring for cardiovascular (CV) risk stratification. METHODS: A total of 108 patients (43 VKA users with MPV and 65 gender-, age-, and risk-factor-matched VKA-free patients) were included in the study. CAC was determined via computed tomography (CT) and quantified on the basis of the Agatston score. The VKA group comprised patients who had an MPV for longer than 5 years, which entailed long-term VKA use. RESULTS: Long-term VKA users had more calcified coronary arteries compared with the control group (178.1 ± 278 vs. 61.1 ± 130.6, p = 0.01). There was no difference between groups in terms of traditional CV risk factors. The mean duration of VKA use was 15 ± 7 years for the patients with MPV. There was no correlation between the duration of VKA use and mean Agatston score (r = 0.2, p = 0.215). CONCLUSION: With its unique selection of patient groups, our study extends the findings of previous research that long-term VKA use is related to CAC as detected via CT scanning. The longer and more potent VKA regimen required for MPV patients is the primary cause of CAC in this group.

Acute Anterior Myocardial Infarction Accompanied by Acute Inferior Myocardial Infarction: A Very Rare Coronary Artery Anomaly.

Coronary artery anomalies are rare and mostly silent in clinical practice. First manifestation of this congenital abnormality can be devastating as syncope, acute coronary syndrome, and sudden cardiac death. Herein we report a case with coronary artery anomaly complicated with ST segment myocardial infarction in both inferior and anterior walls simultaneously diagnosed during primary percutaneous coronary intervention.

Misdiagnosis of carbon monoxide intoxication in a patient with known coronary artery disease: a case report and review of cardiovascular effects of carbon monoxide poisoning / Mal diagnóstico de intoxicación por monóxido de carbono en un paciente diagnosticado con enfermedad de la arteria coronaria: reporte de un caso y estudio de los efectos cardiovasculares del envenenamiento por monóxido de carbono

This is a report of a patient who had documented coronary artery disease and was admitted with chest pain, nausea, vomiting and headache. She was immediately taken to coronary angiography and underwent percutaneous coronary intervention with stent implantation. After the operation, she was coincidentally diagnosed to have Carbon Monoxide (CO) poisoning. We discuss if percutaneous intervention (PCI) was an overtreatment and briefly review the mechanisms of the cardiovascular effects of CO toxicity which is an insidious pathology and diagnosed only if it is suspected.

Este es un reporte de una paciente con enfermedad de la arteria coronaria documentada, quien fuera ingresado con dolor de pecho, náuseas, vómitos y dolor de cabeza. A la paciente se le hizo inmediatamente una angiografía coronaria y se le realizó una intervención coronaria percutánea con implantación de stent. Después de la operación, se le diagnosticó por coincidencia envenenamiento por monóxido de carbono (CO). Analizamos si la intervención percutánea (IPC) fue un sobretratamiento y examinamos brevemente los mecanismos de los efectos cardiovasculares de la toxicidad por CO que puede ser insidiosa y diangosticada sólo si se tiene sospecha.

Misdiagnosis of carbon monoxide intoxication in a patient with known coronary artery disease--a case report and review of cardiovascular effects of carbon monoxide poisoning.

This is a report of a patient who had documented coronary artery disease and was admitted with chest pain, nausea, vomiting and headache. She was immediately taken to coronary angiography and underwent percutaneous coronary intervention with stent implantation. After the operation, she was coincidentally diagnosed to have Carbon Monoxide (CO) poisoning. We discuss if percutaneous intervention (PCI) was an overtreatment and briefly review the mechanisms of the cardiovascular effects of CO toxicity which is an insidious pathology and diagnosed only if it is suspected.

Unusual causes of small bowel obstruction and contemporary diagnostic algorithm.

Intestinal obstruction is a common clinical abnormality. In 60-80% of cases, the small bowel is affected. Although postoperative adhesions are responsible in 60% of cases, the other frequently observed causes are hernia, strangulation and tumours, such as carcinoid, lymphoma or adenocarcinoma. In this pictorial essay, we presented the radiological findings of uncommon causes of small bowel obstruction as well as the suggested diagnostic algorithm.

Direct stenting in angiographically apparent thrombus-containing lesions.

The data regarding the potential benefits of direct stenting in the setting of angiographically apparent thrombus-containing lesions are scarce. The aim of this study was to evaluate the impact of direct stenting on the angiographic results in the setting of thrombus. We reviewed our institutional interventional database and identified 30 patients who had undergone stenting in the setting of angiographically apparent thrombus-containing lesions (33% unstable angina pectoris, 67% acute myocardial infarction). The majority of patients had a baseline TIMI 2 and 3 flow (80%). Of the 6 patients (20%) who had TIMI 0-1 flow at baseline, four of them achieved a TIMI 2 flow immediately after crossing the lesion with a 0.014 guidewire. Although the remaining 2 patients had TIMI 1 flow, as distal opacification beyond the stenosis was obtained we successfully implanted the stents directly. All stents were successfully implanted without any crossing failure or stent loss. There was no "no re-flow", with a final TIMI 3 flow rate in 93%. In 1 patient with TIMI 2 flow after stenting, TIMI 3 flow was obtained after intracoronary verapamil. In 2 patients (7%, TIMI 2 flow), a final TIMI 3 flow could not be achieved despite intracoronary nitroglycerin and verapamil. There was no stent loss and imprecise stent placement. There were no in-hospital deaths, repeat interventions or coronary artery bypass graft surgeries. However, two patients had undergone mitral valve replacement due to severe mitral regurgitation. Eight patients with recurrent ischemia had control angiography; stents were found to be patent in all 8 patients. Two patients experienced recurrent myocardial infarction (6.6%). Direct stenting strategy in thrombus-containing lesions seems to be a safe and feasible approach in avoiding no re-flow. We believe that benefits observed with direct stenting in this study should be compared to conventional stenting in the same setting with a randomized study.

Stenting of the septal perforator coronary artery.

This report describes the first application of intracoronary stenting to the septal perforator coronary artery in a patient with a totally occluded left anterior descending coronary artery (LAD) and a patent venous graft to the distal LAD. The procedure was successful and resulted in almost complete relief of class III angina. Therefore, diseased large septal perforators may cause angina and be treated effectively by intracoronary stenting in selected cases.

Adjunctive therapies in the cath lab. Intracoronary tirofiban infusion in a case with massive intracoronary thrombus.

By inhibiting platelet aggregation, glycoprotein IIb/IIIa inhibitors prevent arterial occlusion and reduce ischemic complications in the setting of acute ischemic coronary syndromes associated with intracoronary thrombus. There are also accumulating data in the literature regarding the local use of these agents for thrombus dissolution. We report a case with massive right coronary artery thrombus in which the thrombus was successfully dissolved with intracoronary tirofiban infusion. To the best of our knowledge, this is the first case of this kind.

Primary angioplasty and stenting in a patient with primary antiphospholipid syndrome and thrombocytopenia.

Antiphospholipid syndrome is characterized by venous and arterial thrombosis, thrombocytopenia, stroke and, rarely, acute coronary syndromes. However, there are no data available regarding the management of acute myocardial infarction in primary antiphospholipid syndrome with accompanying severe thrombocytopenia and cardiogenic shock. We describe such a case, which was managed by successful primary percutaneous transluminal coronary angioplasty and stent implantation with accompanying immunosuppression therapy.

Alterations in cardiac flow parameters in patients with polycystic ovarian syndrome.

The aim of this study was to examine the echocardiographic profiles of patients with polycystic ovarian syndrome (PCOS). Serum concentrations of follicle stimulating hormone, luteinizing hormone, androstenedione, free testosterone, prolactin, DHEA-SO(4) and 17-OH-progesterone, lipid profile (high and low density lipoproteins, triglyceride and total cholesterol) and basal and total insulin after a glucose tolerance test were measured in 35 patients with PCOS and 35 healthy controls matched for body mass index. Doppler, two dimensional M mode echocardiography was performed for the following indices: isovolumetric relaxation time (IVRT), E wave duration time (EVT), A wave duration time (AVT), E wave deceleration time (DT), peak early diastolic flow velocity (PEV), peak late diastolic flow velocity (PAV), E wave velocity time integral (FVI-E), A wave velocity time integral (FVI-A), atrial filling fraction (AFF), ejection fraction (EF), pre-ejection time (PEP), ejection time (ET) and aortic flow velocity time integral (FVI). Androstenedione, free testosterone, low density lipoproteins and cholesterol concentrations were significantly higher in patients with PCOS. There was no difference in basal and total insulin concentrations. IVRT, AVT, FVI-A, AFF, and PEP were higher in patients with PCOS, while PEV, FVI-E, EF, ET, EVT and EVT/AVT were higher in the control group. There was a positive correlation between basal insulin values and IVRT, and between total insulin values and EF. These changes are consistent with a non-restrictive type of diastolic dysfunction and left ventricular stiffness. PCOS may lead to diastolic dysfunction via hyperinsulinaemia and male type dyslipidaemia.

Left atrial free floating thrombus. Diagnosis by two dimensional and M-mode echocardiography.

Left atrial thrombus, which is a frequent finding in patients with mitral valve disease, is generally attached to the atrial wall. Left atrial free-floating thrombus has rarely been reported. Since the risk of peripheral emboli is fairly high, patients with such a thrombus are candidates for emergency surgery. Our first case was a 45-year-old female with mitral stenosis and regurgitation. The typically appearing free floating thrombus with a diameter of 3.4 cm was detected by two-dimensional and M-mode echocardiography, and an appropriate surgical procedure was performed. The surgical findings were consistent with the echocardiographic findings. Our second case was a 59-year-old female. A free floating thrombus with a diameter of 2 cm was detected by echocardiography when this patient with mitral stenosis was hospitalized because of right hemiplegia and aphasia. The thrombus was extracted by an immediate surgical procedure. Transthoracic echocardiographic (TTE) study was definitely specific in both cases; no other study was thus required.