Half-Dose tPA for Massive Pulmonary Thromboembolism After Liposuction.

Background: The most aggressive preventive strategies may fail to prevent pulmonary embolism (PE) after liposuction. PE can cause serious life-threatening consequences and death. If hemodynamic detoriation occurs, treatment is systemic or catheter-directed fibrinolytic therapy and, if failed, surgical embolectomy. A latent risk exists for catastrophic hemorrhage when thrombolytic is administered after surgery. Thus, the use of tissue plasminogen activator (tPA) has never been studied in postoperative patients, and the safety of this medicine is unknown. In this case study, a 31-year-old obese woman was evaluated for complaints of shortness of breath, palpitations, and hypotension in the first postoperative day after liposuction. Conclusions: Successful management of massive PE with a half-dose regimen of tPA (alteplase 50 mg over 2 hours) is reported.

Systemic reduced-dose alteplase for diffuse pulmonary thrombi in a COVID-19 patient.

Pulmonary embolism has a high frequency in COVID-19 patients admitted to the intensive care unit. Low level of fibrinolysis is one of the asserted contributors to a prothrombotic state in COVID-19. Thrombotic coagulopathy is mostly encountered as diffuse pulmonary thrombi. Diffuse pulmonary microemboli was treated successfully with reduced dose thrombolysis.

Incidental diagnosis of right-to-left atrial shunt by computed tomography.

The existence and direction of an atrial shunt is normally diagnosed using echocardiography. A right-to-left atrial shunt, uncovered on routine computed tomography angiography, is presented. Transthoracic echocardiography verified the atrial shunt. TTE with intravenous agitated saline revealed the appearance of microbubbles in the left side of the heart. Atrial septal defects are a common cause of congenital heart diseases in adulthood. It may remain silent for decades because of the asymptomatic nature of the disease. Right-to-left atrial shunt is uncommon in patients with ASD.

Moxifloxacin Monotherapy in Left-Sided Staphylococcus aureus Endocarditis.

Staphylococcus aureus is the major cause of endocarditis, and its mortality has remained high despite therapeutic procedures over time. A case of left-sided native valve endocarditis caused by methicillin-sensitive Staphylococcus aureus which responded well to moxifloxacin monotherapy is described. An 83-year-old woman with a history of current hospitalization presented with fatigue and fever. Transthoracic echocardiography depicted vegetation, and blood cultures were positive for Staphylococcus aureus. After a 14-day intravenous administration of moxifloxacin, a good clinical response was achieved, and antibiotic regimen transitioned to oral moxifloxacin for an additional four-week therapy.

Atrial conduction time, and left atrial mechanical and electromechanical functions in patients with polycystic ovary syndrome: interatrial conduction delay.

BACKGROUND: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders of women during the reproductive period. Cardiovascular risk factors are more frequent in patients with PCOS. We aimed to investigate the P-wave dispersion (Pd), inter- and intra-atrial conduction time and mechanical functions of the left atrium (LA) in patients with PCOS. METHODS: Forty-eight patients with PCOS and 38 normal healthy women were enrolled in this study. A 12-lead surface electrocardiogram was used to evaluate Pd. Left ventricular (LV) functions were measured using conventional and tissue Doppler imaging (TDI) methods. Inter- and intra-atrial conduction times were measured by TDI. LA volumes were measured echocardiographically with the biplane area-length method from the apical four-chamber view. RESULTS: Heart rate (82.02 ± 13.15 vs 74.24 ± 11.02 bpm, p = 0.014) and Pd were significantly increased in the PCOS patients [27 ± 5 vs 24 ± 6 ms, p = 0.035]. Transmitral E/A ratio was significantly lower in the PCOS patients than in the controls (1.5 ± 0.3 vs 1.7 ± 0.4 m/s, p = 0.023). Passive emptying volume (12.54 ± 4.39 vs 15.28 ± 3.85 ml/m(2), p = 0.004) and passive emptying fraction [54.4 (21-69) vs 59.1% (28-74), p = 0.008] were significantly decreased in PCOS patients. Total emptying volume was significantly decreased (17.9 ± 5.49 vs 20.67 ± 4.29 ml/m(2), p = 0.018) in PCOS patients. Interatrial (19 ± 7.4 vs 15 ± 6.4 ms, p = 0.035) and intra-atrial [8.5 (1-19) vs 5 ms (1-20), p = 0.026] electromechanical delays were found to be significantly higher in PCOS patients. CONCLUSION: This study showed that patients with PCOS had increased inter- and intra-atrial conduction delays, and decreased LA passive emptying volumes and fractions.

Predictors of in-hospital mortality following redo cardiac surgery: Single center experience.

PURPOSE: Redo cardiac operations represent one of the main challenges in heart surgery. The purpose of the study was to analyze the predictors of in-hospital mortality in patients undergoing reoperative cardiac surgery by a single surgical team. METHODS: A total of 1367 patients underwent cardiac surgical procedures and prospectively entered into a computerized database. Patients were divided into 2 groups based on the reoperative cardiac surgery (n = 109) and control group (n = 1258). Uni- and multivariate logistic regression analysis were performed to evaluate the possible predictors of hospital mortality. RESULTS: Mean age was 56 ± 13, and 46% were female in redo group. In-hospital mortality was 4.6 vs. 2.2%, p = 0.11. EuroSCORE (6 vs. 3; p < 0.01), cardiopulmonary bypass time (90 vs. 71 min; p < 0.01), postoperative bleeding (450 vs. 350 ml; p < 0.01), postoperative atrial fibrillation (AF) (29 vs. 16%; p < 0.01), and inotropic support (58 vs. 31%; p = 0.001) were significantly different. These variables were entered into uni- and multivariate regression analysis. Postoperative AF (OR1.76, p = 0.007) and EuroSCORE (OR 1.42, p < 0.01) were significant risk factors predicting hospital mortality. CONCLUSIONS: Reoperative cardiac surgery can be performed under similar risks as primary operations. Postoperative AF and EuroSCORE are predictors of in-hospital mortality for redo cases.

Transcatheter aortic valve implantation in a patient with bicuspid aortic stenosis and a borderline-sized annulus.

Bicuspid aortic valve (BAV) is currently considered an exclusion criterion for transcatheter aortic valve implantation (TAVI). The risk of adverse aortic events such as incomplete sealing, severe paravalvular regurgitation or dislocation due to elliptic shape and asymmetric calcifications in annulus are higher in TAVI. In this case report, we detailed a case of successful trans-femoral TAVI in a 51-year old male with BAV and its management without in-hospital and 30-day complications. The challenge in this case was the patient's anatomy with a 27-mm annulus for balloon expandable device. The applied strategy was balloon sizing and overdilating the 29-mm stented valve with additional volume that obviated re-ballooning. Trans-femoral TAVI was performed uneventfully under fluoroscopic and transoesophageal echocardiography guidance. A multidetector computed tomography (MDCT) evaluation at 1 month did not show device dislodgement or any other complications. Evidence for evaluation post-TAVI is not sufficient in BAV. We believe patients with BAV should undergo a comprehensive assessment after TAVI including MDCT evaluation.

Retrograde pedal access with a 20-gauge intravenous cannula after failed antegrade recanalization of a tibialis anterior artery in a diabetic patient: a case report.

Retrograde tibiopedal approach is being used frequently in below-the-knee vascular interventions. In patients with diabetic foot pathology, complex anatomy often requires a retrograde technique when the distal vascular anatomy and puncture site is suitable. The dorsalis pedis and posterior tibial arteries can be punctured because of their relatively superficial position. We report a retrograde puncturing technique in patients with chronic total occlusions. After failed antegrade recanalization, puncturing and cannulation of a tiny dorsalis pedis artery with a narrow bore [20-gauge (0.8 mm)] intravenous cannula is described.

TAP-Stenting Technique for Bifurcation Stenosis of Celiac Artery.

We report a clinical course of a patient who developed severe ischemic liver injury and total occlusion of the celiac artery (CA). A 40-year-old man presented with abdominal pain. Computed tomography indicated total occlusion of the CA. Laboratory data demonstrated markedly elevated hepatic enzymes. An exploratory laparotomy was not necessitated due to absence of peritonism. The patient was successfully treated by endovascular recanalization of the CA occlusion via transcatheter balloon angioplasty and TAP-stenting (T-stenting and small protrusion) technique. Endovascular intervention in patients solely with liver failure appears practicable and early treatment is advised.

Fragmented QRS is associated with frequency of premature ventricular contractions in patients without overt cardiac disease.

OBJECTIVE: In this study, we aimed to demonstrate whether the presence of fragmented QRS (fQRS) is associated with the frequency of premature ventricular contractions (PVCs). METHODS: We retrospectively analyzed 282 cases by 24-hour Holter monitorings (HMs) between August 2012 and February 2013. Firstly, the patients were divided into 2 groups with respect to presence of fQRS and then divided into 3 groups with respect to frequency of PVCs as Group 1: seldom PVC (<120 PVCs/day), Group 2: moderate-frequency PVC (120-720 PVCs/day), and Group 3: frequent PVC (>720 PVCs/day). We investigated the predictors of frequent PVCs by using multinomial logistic regression analysis. RESULTS: Ninety-eight patients had fQRS. There was no difference between the 2 groups with respect to body mass index, gender, hypertension, and diabetes mellitus. Patients with fQRS were older (54.9±15.6 vs. 47.0±16.3, p<0.001) and had more family history of coronary artery disease (25% vs. 13%, p=0.012). Patients with fQRS was more likely to be on aspirin therapy (28.6% vs. 10.4%, p<0.001) and have a larger left atrium diameter (33.5±5.7 vs. 30.4±5.8, p=0.001). Presence of fQRS was significantly associated with the frequency of PVCs (for frequent PVC 27.7% vs. 7.6%, p<0.001; for moderate-frequency PVC 18.4% vs. 11.4%, p=0.012); 26.2% of Group 1 (n=202) had fQRS, 46.2% of Group 2 (n=39) had fQRS, and 65.9% of Group 3 (n=41) had fQRS. In the multinomial regression analysis, only age (odds ratio: 4.24, 95% confidence interval 2.08-8.64, p=0.001) and fQRS (odds ratio: 2.11, 95% confidence interval 1.00-4.45, p=0.05) were predictors of frequent PVCs. CONCLUSION: This study demonstrated that the presence of fQRS is associated with frequent PVCs in patients without overt structural heart disease.

Intercellular adhesion molecule-1 K469E and angiotensinogen T207M polymorphisms in coronary slow flow.

OBJECTIVE: To investigate intercellular adhesion molecule-1 (ICAM1) and angiotensinogen (AGT) gene polymorphisms, as related to atherosclerosis and endothelial dysfunction, in coronary slow flow (CSF). SUBJECTS AND METHODS: The participants in this study were 48 patients with CSF and 67 patients with normal coronary flow as controls. The K469E polymorphism of ICAM1 (rs5498) and the T207M polymorphism of AGT (rs4762) were determined using the polymerase chain reaction amplification method. RESULTS: Baseline demographic parameters were similar in both groups. The mean thrombolysis in myocardial infarction frame count was significantly higher in patients with CSF (23.8 ± 5.1) compared to the controls (13.3 ± 2.6, p < 0.001). A significant association was found between the ICAM1 K allele and CSF (OR: 1.96, 95% CI: 1.15-3.35, p = 0.013). There was no difference in the frequency of AGT T207M genotypes in the patients with CSF and the control subjects. CONCLUSION: This study showed that K469E polymorphisms of ICAM1 that play a role in atherosclerotic pathogenesis are related to CSF.

Atrial electromechanical coupling intervals in pregnant subjects.

OBJECTIVE: The aim of this study was to evaluate atrial conduction abnormalities obtained by tissue Doppler imaging (TDI) and electrocardiogram analysis in pregnant subjects. METHODS: A total of 30 pregnant subjects (28 ± 4 years) and 30 controls (28 ± 3 years) were included. Systolic and diastolic left ventricular (LV) function was measured using conventional echocardiography and TDI. Inter-atrial, intraatrial and intra-left atrial electromechanical coupling (PA) intervals were measured with TDI. P-wave dispersion (PD) was calculated from a 12-lead electrocardiogram. RESULTS: Atrial electromechanical coupling at the septal and left lateral mitral annulus (PA septal, PA lateral) was significantly prolonged in pregnant subjects (62.1 ± 2.7 vs 55.3 ±3.2 ms, p < 0.001; 45.7 ± 2.5 vs 43.1 ± 2.7 ms, p < 0.001, respectively). Inter-atrial (PA lateral - PA tricuspid), intra-atrial (PA septum - PA tricuspid) and intra-left atrial (PA lateral - PA septum) electromechanical coupling intervals, maximum P-wave (Pmax) duration and PD were significantly longer in the pregnant subjects (26.4 ± 4.0 vs 20.2 ± 3.6 ms, p < 0.001; 10.0 ± 2.0 vs 8.0 ± 2.6 ms, p = 0.002; 16.4 ± 3.3 vs 12.2 ± 3.0 ms, p < 0.001; 103.1 ± 5.4 vs 96.8 ± 7.4 ms, p ± 0.001; 50.7 ± 6.8 vs 41.6 ± 5.5 ms, p < 0.001, respectively). We found a significant positive correlation between inter-atrial and intraleft atrial electromechanical coupling intervals and Pmax (r = 0.282, p = 0.029, r = 0.378, p = 0.003, respectively). CONCLUSION: This study showed that atrial electromechanical coupling intervals and PD, which are predictors of AF, were longer in pregnant subjects and this may cause an increased risk of AF in pregnancy.

Evaluation of coronary artery-saphenous vein composite grafts: the aortic no-touch technique.

We retrospectively compared the results of conventional coronary artery bypass grafting (CABG) performed on patients who showed no preoperative evidence of serious atherosclerosis of the ascending aorta with the results of the aortic no-touch technique (using coronary artery-saphenous vein composite grafts) on CABG patients who did show such evidence. From 2003 through 2012, 3,152 consecutive patients underwent isolated primary CABG at our hospital. We chose 360 for the current study. The study group (n=120) comprised patients who had undergone operation via the aortic no-touch technique. Propensity-score-matching (1:2) was used to select the control group of 240 patients who had undergone conventional CABG. Early and late survival rates, reintervention-free survival rates, and freedom from cardiac death were compared. Early and late mortality rates were similar in the study and control groups (P=0.19 vs P=0.29, respectively), as were cardiac-related death (2.5% vs 2.1%, respectively; P=0.53) and overall death (8.3% vs 7.9%, respectively; P=0.51). Overall survival rates were 91.7% vs 92.1% and freedom-from-cardiac-death rates were 97.4% vs 97.5% (P=0.71 vs P=0.78, respectively; mean follow-up period, 5.27 ± 2.51 yr). Reintervention-free survival rates were also similar (96.7% vs 98.8%, respectively; P=0.2). As a result of the similar rates of early and late survival, reintervention-free survival, and freedom from cardiac death, we conclude that the aortic no-touch technique with composite grafts might be a reasonable option in patients who have atherosclerotic ascending aorta that cannot be clamped.

Endothelial function and germ-line ACE I/D, eNOS and PAI-1 gene profiles in patients with coronary slow flow in the Canakkale population: multiple thrombophilic gene profiles in coronary slow flow.

BACKGROUND: We examined the effects of ACE, PAI-1 and eNOS gene polymorphisms on endothelial function. The genes are related to atherosclerosis and endothelial dysfunction in coronary slow flow (CSF). METHODS: Thirty-three patients with angiographically proven CSF and 48 subjects with normal coronary flow were enrolled in this study. Coronary flow patterns were determined by the thrombolysis in myocardial infarction (TIMI) frame count method. Endothelial function was assessed in the brachial artery by endothelium-dependent flow-mediated dilatation (FMD). PAI-1 4G/5G, eNOS T-786C and ACE I/D polymorphisms were determined by polymerase chain reaction (PCR) amplification. RESULTS: No difference was found between the groups regarding age, heart rate and blood pressure. Males were more prevalent among patients with CSF than control subjects (58.8 vs 29.8%, p = 0.009). Mean TIMI frame counts were significantly higher in CSF patients (24.2 ± 4.0 vs 13.1 ± 2.5 fpm, p = 0.001). FMD was significantly lower in CSF patients than in the controls (4.9 ± 6.6 vs 7.9 ± 5.6%, p = 0.029). TIMI frame count and FMD were found to be negatively correlated in a correlation analysis (r = -0.269, p = 0.015). PAI-1 4G/5G, eNOS T-786C and ACE I/D polymorphisms were similar in the two groups. CONCLUSIONS: This study showed that endothelial function was impaired in patients with CSF. PAI-1, ACE and eNOS polymorphisms were not related to CSF in our study population.

Epicardial adipose tissue thickness in hemodialysis patients.

AIM: Hemodialysis (HD) patients had higher cardiovascular mortality and it is related to atherosclerosis. Epicardial adipose tissue (EAT) thickness is a marker of atherosclerosis and independent predictor of coronary artery disease. The aim of our study was to evaluate the relationship between EAT and carotid intima-media thickness (CIMT) predictors of early atherosclerosis in HD patients. METHODS: The study included 62 HD patients and 40 healthy controls. EAT thickness and CIMT were measured by echocardiography in all subjects. RESULTS: Epicardial adipose tissue thickness and CIMT were higher (6.98 ± 1.67 vs. 3.84 ± 0.73 mm, P < 0.001, 0.94 ± 0.17 vs. 0.63 ± 0.11 mm, P < 0.001, respectively) in HD patients than in control subjects. EAT thickness were correlated with CIMT, HD duration, age, and calcium. In addition, HD duration, CIMT, and age were independent predictors of EAT thickness on HD patients in regression analysis. CONCLUSION: Epicardial adipose tissue thickness may be a useful indicator of early atherosclerosis in HD patients.