Clinical Characteristics and Outcome of Cardiovascular Implantable Electronic Device Infections in Turkey.

Infection is one of the most devastating outcomes of cardiovascular implantable electronic device (CIED) implantation and is related to significant morbidity and mortality. In our country, there is no evaluation about CIED infection. Therefore, our aim was to investigate clinical characteristics and outcome of patients who had infection related to CIED implantation or replacement. The study included 144 consecutive patients with CIED infection treated at 11 major hospitals in Turkey from 2005 to 2014 retrospectively. We analyzed the medical files of all patients hospitalized with the diagnosis of CIED infection. Inclusion criteria were definite infection related to CIED implantation, replacement, or revision. Generator pocket infection, with or without bacteremia, was the most common clinical presentation, followed by CIED-related endocarditis. Coagulase-negative staphylococci and Staphylococcus aureus were the leading causative agents of CIED infection. Multivariate analysis showed that infective endocarditis and ejection fraction were the strongest predictors of in-hospital mortality.

Metabolic syndrome is associated with atrial electrical and mechanical dysfunction.

OBJECTIVE: In this study, we aimed to investigate the left atrial (LA) electrical and mechanical functions in patients with metabolic syndrome (MetS). SUBJECTS AND METHODS: The study population consisted of 87 patients with MetS and 67 controls. Intra-atrial and interatrial electromechanical delays (EDs) were measured with tissue Doppler imaging. P-wave dispersion (Pd) was calculated from the 12-lead electrocardiograms. LA volumes were measured echocardiographically by the biplane area-length method. RESULTS: Intra-atrial and interatrial EDs and Pd were significantly higher in patients with MetS (10.3 ± 6.3, 21.0 ± 11.5 and 41.7 ± 10.8) than in controls (7.4 ± 5.5, 12.3 ± 10.4 and 29.2 ± 7.4; p = 0.003, p < 0.001 and p < 0.001, respectively). The LA preatrial contraction volume and active emptying volumes were higher in this population, but the LA passive emptying fraction was lower. In the multivariate linear regression analysis, the presence of MetS, LA active emptying volume and left ventricular early diastolic (E) wave velocity/late diastolic (A) wave velocity (E/A) ratios were independent correlates of interatrial ED (p = 0.002, p = 0.001 and p = 0.025, respectively). CONCLUSIONS: This study showed that intra-atrial and interatrial EDs and Pd were prolonged and LA mechanical functions were impaired in patients with MetS.

A rare manifestation of atrial fibrillation in the presence of Wolff-Parkinson-White syndrome: tachycardia-induced cardiomyopathy.

We report a 68-year-old man who presented with heart failure and atrial fibrillation (AF) with rapid ventricular response and wide QRS complexes. Tachycardia-induced cardiomyopathy (TIC) due to persistent AF developing on the basis of Wolff-Parkinson-White (WPW) syndrome was considered. Signs and symptoms of heart failure improved with restoration of sinus rhythm. This case suggested that persistent AF in a patient with WPW syndrome is one of the rare causes of TIC.

The presence of fragmented QRS on 12-lead ECG in patients with coronary slow flow.

BACKGROUND: Coronary slow flow (CSF) is characterised by delayed opacification of coronary arteries in the absence of epicardial occlusive disease. It has been reported that CSF may cause angina, myocardial ischaemia, and infarction. Fragmentation of QRS complex (fQRS) is an easily evaluated non-invasive electrocardiographic parameter. It has been associated with alternation of myocardial activation due to myocardial scar and/or ischaemia. Whether CSF is associated with fQRS is unknown. The presence of fQRS on ECG may be an indicator of myocardial damage in patients with CSF. AIM: To investigate the presence of fQRS in patients with CSF. METHODS: Sixty patients (mean age 55.5 ± 10.5 years) with CSF and 44 patients with normal coronary arteries without associated CSF (mean age 53 ± 8.4 years) were included in this study. The fQRS was defined as the presence of an additional R wave or notching of R or S wave or the presence of fragmentation in two contiguous leads corresponding to a major coronary artery territory. RESULTS: The presence of fQRS was higher in the CSF group than in the controls (p = 0.005). Hypertension was significantly more common in the CSF group (p < 0.001). There was no significant association between the presence of fQRS and an increasing number of vessel involvements. Logistic regression analysis demonstrated that the presence of CSF was the independent determinant of fQRS (OR = 10.848; 95% CI 2.385-49.347; p = 0.002). CONCLUSIONS: Fragmented QRS, indicating increased risk for arrhythmias and cardiovascular mortality, was found to be significantly higher in patients with CSF. We have not found an association between the presence of fragmented QRS and the degree of CSF. Further prospective studies are needed to establish the significance as a possible new risk factor in patients with CSF.

Left ventricular remodeling assessment in patients with anterior acute myocardial infarction treated with successful primary percutaneous coronary intervention: an observational study.

OBJECTIVE: We aimed to analyze the left ventricular (LV) remodeling in patients treated with coronary intervention (PCI) in the acute phase of anterior myocardial infarction (MI) and to analyze the relationship between LV functional remodeling and residual viability in the infarct zone detected by thallium-201 (Tl-201) imaging and echocardiography. METHODS: We designed an observational prospective cohort study including 30 patients (26 men, 4 women, mean age; 52±12 years old) with acute anterior MI. Echocardiography and Tl-201 imaging were performed in all patients three days and two months after PCI and left ventricular end-systolic volume (ESV), left ventricular end-diastolic volume (EDV), ejection fraction (EF) and summed redistribution score (SRS) were calculated. Paired samples t- test or Wilcoxon rank sign test for comparing continuous variables in dependent groups, Pearson correlation for testing relationship between continuous variables were used. RESULTS: Left ventricular function baseline values just after PCI and two months after PCI obtained by echocardiography and scintigraphy were statistically significant. Among patients 76.7% had an EF ≥0.50 after the event. EDV and ESV values are significantly low when compared to values two months before. There was not any marked change in SRS in five patients. Polar maps were correlated with heart rate (r=0.438; p=0.023), peak creatine kinase MB (r=0.440; p=0.015) and troponin (r=0.471; p=0.009) during acute MI. CONCLUSION: Significant recovery in EDV, ESV and SRS values, and increase in EF two months after the infarction shows us substantial part of the remodeling process is completed in two months and Tl-201 imaging is extremely effective in determining of salvaged myocardium.

Atrioventricular block in patients with thyroid dysfunction: prognosis after treatment with hormone supplementation or antithyroid medication.

BACKGROUND: Hypothyroidism is a reversible cause of atrioventricular (AV) block. Few reports have described reversible AV block caused by hyperthyroidism. However, it is unknown whether patients with AV block are expected to have a benign course after the initiation of appropriate therapy for thyroid dysfunction. METHODS: The study group consisted of patients with II or III degree AV block and bradyarrhythmia (≤40bpm) excluding patients with myocardial infarction, electrolyte abnormalities, digitalis toxicity, and vasovagal syncope. Thyroid dysfunction is diagnosed when thyroid stimulating hormone and thyroxine levels are not in defined normal ranges. AV block was determined by surface electrocardiogram (ECG). The cause and effect relation between AV block and thyroid dysfunction was evaluated. RESULTS: Of 668 patients, 29 (4.3%) had hypothyroidism (19 overt) and 21 (3.1%) had hyperthyroidism (8 overt). The most frequent ECG finding was complete AV block (27 of 50 patients). Ten patients had bradyarrhythmia and 13 had second-degree AV block. Euthyroid state was achieved in 10 hypothyroidic (34%) and in 7 hyperthyroidic patients (33%) with hormone replacement and antithyroid therapy, respectively, during the follow-up period (≤21 days). Thyroid dysfunction was found to be not related with AV block in 40 patients (80%). However, in 4 of 10 patients with AV block related to thyroid dysfunction the resolution of AV block occurred after the placement of pacemaker (>21 days). Overall, 44 of 50 (88%) patients with AV block in association with thyroid dysfunction were implanted with a permanent pacemaker. Of 6 patients who did not receive a pacemaker, 2 had complete AV block and 4 had bradyarrythmia. CONCLUSION: AV block associated with thyroid dysfunction needs great attention regardless of type of the thyroid disease. Patients with II and/or III degree AV block in the setting of thyroid dysfunction almost always need permanent pacemaker insertion even after normalization of thyroid status.

Management of patients with drug-induced atrioventricular block.

OBJECTIVE: To identify the frequency of atrioventricular (AV) conduction improvement after discontinuation of the culprit drug in patients with AV block. BACKGROUND: AV blockers are considered as reversible causes of AV block that do not require pacemaker (PM) implantation. However, controversial reports declared that a major part of these drug-induced AV blocks are persistent or recurrent. METHODS: Of 668 consecutive patients with symptomatic type II second- or third-degree AV block, 2:1 AV block, atrial fibrillation, and bradyarrhythmia, 108 patients (62 patients enrolled prospectively) using AV blockers without myocardial infarction, electrolyte abnormalities, digitalis toxicity, and vasovagal syncope were enrolled into the present study. The level of AV block (AV-nodal or infranodal) was defined according to electrocardiographic characteristics. RESULTS: The most frequent culprit medications were ß-blockers followed by digoxin. Drug discontinuation was followed by resolution of AV block in 72% of cases, whereas spontaneous resolution of AV block occurred in only 6.6% of patients who had AV block in the absence of medications. However, 27% of patients with improved AV conduction experienced a recurrence of AV block despite discontinuation of the culprit drug. Twenty-one of 24 carvedilol-induced AV blocks resolved after discontinuation of the drug and never recurred, whereas 24 of 36 metoprolol-induced AV blocks persisted or recurred. A digoxin-induced AV block usually improved (28 of 39) after withdrawal of the drug. Roughly half of the patients with drug-induced AV block underwent permanent PM implantation. CONCLUSION: Drug-induced AV block is a serious disease that requires a permanent PM for almost half of the patients.

Alzheimer's disease: is pacemaker implantation safe?

AIM: To evaluate the safety of pacemaker implantation in patients with Alzheimer's disease (AD). METHODS: We reviewed all cases admitted to our institution between January 2008 and June 2009, with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. Patients with a diagnosis of AD were included in the study. The risks and frequency of complications due to the pacemaker implantation were evaluated. Because of the older age of patients, they were divided into 2 groups to define the effect of age on complication rate. Group 1 consisted of patients aged <75 years, and group 2 consisted of those who are ≥75 years. RESULTS: Among the 574 patients with permanent pacemaker, 20 patients (3.4%) had a diagnosis of AD. Three patients with an AD experienced a complication and all were in group 2. However, the rate of complication was not significant within groups (P = 1.000). Reoperation was needed for all of them, and it was significantly higher in patients with AD than in patients without a concomitant disease (P = .006). Patients in group 2 had 3 times higher rate of complication (21.4%) than those without an AD and aged ≥75 years (7.1%; P = .125). CONCLUSION: Pacemaker implantation may be of risk in patients with AD, especially in those aged ≥75 years.

[CyberKnife can cause inappropriate shock]. / Uzay nesteri (CyberKnife) uygunsuz sok nedeni olabilir.

Implantable cardioverter-defibrillators (ICD) have been increasingly used to treat life-threatening ventricular tachyarrhythmias. Although they have life-saving capabilities, they are very sensitive to electromagnetic energy sources. It has been reported that many problems associated with the detection of tachyarrhythmias and termination of the mechanism of the ICDs occur due to electromagnetic interference (EMI). In spite of the fact that EMI has been decreasingly observed with the latest generation ICDs, problems may still occur during radiotherapy. The CyberKnife is the latest stereotactic radio-surgery technology in the field of radiotherapy, and is currently being used for the treatment of malign neoplasm in the body. It is especially preferred for the treatment of advanced stage and metastatic tumors. Five ICD shocks were detected in a patient during a routine follow-up visit. When the patient was evaluated, it was determined that he underwent radiotherapy with CyberKnife technology because of lung metastasis and rectal adenocarcinoma. He received the ICD shocks while he was on radiotherapy. When the stored intracardiac electrograms in the memory of the ICD were investigated, it was established that the shocks were inappropriate shocks due to oversensing because of the exposure to EMI.

Ventricular tachycardia: first manifestation of myotonic dystrophy.

Myotonic dystrophy type 1 (DM1) is the most frequent muscular dystrophy in adults. It is a multisystem disorder also affecting the heart with an increased incidence of sudden cardiac death. We present a young female patient with ventricular tachycardia (VT) who had no cardiac complaints previously. In this patient, the phenotypic characteristics implying DM1, neuromuscular testing and genetic analysis all confirmed the diagnosis of DM1 and because of the malignant nature of VT, she received an implantable cardioverter/defibrillator.

Coexistent Brugada syndrome and Wolff-Parkinson-White syndrome: what is the first clinical presentation?

The coexistence of Brugada syndrome and Wolff-Parkinson-White (WPW) syndrome is a very rare phenomenon. We describe a 31-year-old patient without any previous cardiac disorder admitted to our hospital due to palpitations and concomitantly diagnosed as WPW syndrome and treated with radiofrequency catheter ablation. He was later diagnosed with Brugada syndrome and followed-up 2 years without any symptoms. We discuss other previously reported cases in literature, in which these two conditions exist simultaneously.

Serum paraoxonase 1 activity in women with metabolic syndrome.

BACKGROUND: Metabolic syndrome (MetS) is a leading risk factor for coronary artery disease (CAD) in women. Reduced paraoxonase 1 (PON1) activity may play a role in the pathogenesis of atherosclerosis through increased susceptibility to lipid peroxidation in patients with MetS. AIM: To examine whether there is a relationship between serum PON1 activity and MetS in women. METHOD: The study group consisted of 54 women with MetS. The NCEP ATP III guidelines were used to define MetS. The control group consisted of 65 women without MetS and CAD. All patients from the MetS group underwent coronary angiography. RESULTS: The PON1 activity and salt-stimulated PON1 activity were not significantly altered in women with MetS when compared to controls (p = 0.902, p = 0.877, respectively). There was no significant difference in PON1 activity (p = 0.159), and salt-stimulated PON1 activity (p = 0.139) between diabetics and non-diabetics. In the MetS group, patients with CAD (n = 16) had significantly reduced PON1 activity and salt-stimulated PON1 activity compared to MetS patients without CAD (p = 0.008 and p = 0.004, respectively). CONCLUSIONS: Serum PON1 activity is significantly reduced in women with CAD and MetS. MetS per se does not alter serum PON1 activities.

Effects of high altitude and sea level on mean platelet volume and platelet count in patients with acute coronary syndrome.

A relationship exists between exposure to high altitude and increased coagulability. Mean platelet volume is a parameter of platelet functions and may be a marker for increased platelet aggregability. The aim of this study was to compare the mean platelet volumes and platelet counts in patients who experienced an acute coronary event at moderately high altitude and at sea altitude. Four hundred and one patients who experienced an acute coronary event were enrolled, of them 211 were born and had been living at the sea level, while 190 were born and had been living at high altitude (at least 2,000 m above the sea level). Patients were compared regarding the mean platelet volumes and platelet counts. The mean platelet volumes were significantly higher in patients living in high altitude (P = 0.001). No statistically significant differences were found among the groups regarding the platelet counts. As a result, this increased MPV values in highlanders who experienced an acute coronary event may reflect increased platelet aggregability.

[Comparison of Doppler echocardiographic parameters before and after ablation in Wolff-Parkinson-White syndrome patients with and without atrial fibrillation]. / Wolff-Parkinson-White sendromunda atriyal fibrilasyonu olan ve olmayan hastalarin ablasyon öncesi ve sonrasi Doppler ekokardiyografik parametrelerinin karsilastirilmasi.

OBJECTIVES: We compared Doppler echocardiographic features before and after radiofrequency catheter ablation (RFCA) performed for Wolff-Parkinson-White (WPW) syndrome in patients with and without atrial fibrillation (AF). STUDY DESIGN: Forty patients with WPW syndrome were evaluated in two groups depending on the presence of AF (6 females, 14 males; mean age 33+/-15 years) and atrioventricular reciprocating tachycardia (AVRT) (8 females, 12 males; mean age 32+/-18 years). Echocardiographic examination was performed in all the patients 24 hours before and after RFCA. Doppler parameters were recorded including E and A transmitral filling velocities and their velocity-time integrals (VTI), mitral diastolic filling time (mDFT), deceleration time, isovolumic contraction and relaxation times, aortic ejection time (ET) and aortic VTI. RESULTS: The most common localization of the accessory pathway was the left lateral wall (n=9) in patients with AF, compared to one patient in the AVRT group. During programmed electrical stimulation, orthodromic AVRT was induced in all the patients with AVRT; of the AF group, six patients had AF and 14 patients exhibited AVRT that degenerated into AF. The two groups did not differ significantly before and after RFCA with regard to two-dimensional and Doppler echocardiographic parameters (p>0.05). Significant changes observed in both groups after RFCA were as follows: increases in A velocity and A wave VTI (p<0.05), decrease in the E/A ratio (p<0.05), prolongation of mDFT (p<0.001), and shortening of aortic ET (p<0.01). Following the procedure, preexcitation disappeared in all the patients and none had tachyarrhythmia. CONCLUSION: There were no echocardiographic parameters associated with AF in patients with WPW syndrome.

The value of admission glycosylated hemoglobin level in patients with acute myocardial infarction.

BACKGROUND: Glycosylated hemoglobin (HbA1c) level on admission is a prognostic factor for mortality in patients with and without diabetes after myocardial infarction. In the present study, the authors examined the relationship between admission HbA1c level and myocardial perfusion abnormalities in patients with acute myocardial infarction. METHODS: One hundred consecutive patients with acute myocardial infarction who were treated with thrombolytic therapy were included in the present prospective study. Blood glucose and HbA1c levels of all patients were measured within 3 h of admission. Patients were divided into three groups according to HbA1c level: 4.5% to 6.4% (n=25), 6.5% to 8.5% (n=28) and higher than 8.5% (n=47). All patients then underwent exercise thallium-201 imaging and coronary angiography to determine ischemic scores and the number of diseased coronary arteries four weeks after admission. RESULTS: Seven patients died within the four-week follow-up period. There was a significant relationship between admission HbA1c level and mortality (P=0.009). Furthermore, there was a significant relationship between HbA1c level and total ischemic scores in patients with acute myocardial infarction (r=0.482; P=0.001). Ischemic scores increased as HbA1c levels increased in patients with acute myocardial infarction. CONCLUSIONS: The results demonstrated that admission plasma glucose and HbA1c levels are prognostic factors associated with mortality after acute myocardial infarction.

Effects of radiofrequency catheter ablation on myocardial performance index and plasma NT-Pro-BNP levels in patients with Wolff-Parkinson-White syndrome.

BACKGROUND: The myocardial performance index (Tei index) is an echocardiographic index of combined systolic and diastolic functions. Brain natriuretic peptide (BNP) and its biologically inactive fragment N-terminal pro-BNP (NT-pro-BNP) are secreted by the heart in response to myocardial stretch. In this study, we investigated Tei index and NT-pro-BNP levels in patients with Wolff-Parkinson-White (WPW) syndrome before and after radiofrequency catheter ablation therapy (RFCA). METHODS: Thirty patients (19 males, 11 females, aged 35.5 +/- 14.4 years) with WPW syndrome were enrolled in this study. Echocardiographic examination was performed before and 24 hours after RFCA. Tei index was calculated using Doppler echocardiography. Blood samples were taken before and 24 hours after RFCA to detect levels of NT-pro-BNP. RESULTS: Although isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT) did not change, aortic ejection time (ET) was decreased after RFCA (276 +/- 22 ms vs 254 +/- 30 ms, P < 0.01). So Tei index was significantly higher in postablation period (0.36 +/- 0.11 vs 0.42 +/- 0.21, P < 0.05). NT-pro-BNP levels did not change significantly after RFCA. CONCLUSIONS: We demonstrated that restoration of normal atrioventricular conduction by RFCA, leads to increase in Tei index but does not effect plasma NT-pro-BNP levels.

Glue (toluene) abuse: increased QT dispersion and relation with unexplained syncope.

Exposure to toluene, one of the major components of glue, can lead to cardiac arrhythmias and sudden sniffing death syndrome. QT dispersion is a useful risk marker for cardiac arrhythmias and sudden cardiac death. The aim of this study was to investigate the effects of glue abuse on QT interval and QT dispersion. The study included 44 patients with inhalant abuse and 34 healthy controls. Patients were divided into three groups: glue abusers with history of unexplained syncope (n = 20), asymptomatic glue abusers (n = 24), and healthy control subjects (n = 34). QT intervals, QT dispersion, and corrected QT dispersion values were measured. QT and corrected QT duration were greater in the symptomatic group than in at the symptomatic group and greater in the asymptomatic group than in controls. QT and corrected QT dispersion in both symptomatic and asymptomatic group were significantly greater than controls (p= .001), and also QT and corrected QT dispersion in symptomatic group was greater in asymptomatic group (p = .001). These findings demonstrate that QT interval and corrected QT dispersion increase in symptomatic or asymptomatic toluene abusers. The QT and QTc dispersion were also found to be longer in the symptomatic group than those in the asymptomatic group.

High sensitivity CRP levels predict atrial tachyarrhythmias in rheumatic mitral stenosis.

BACKGROUND: The different levels of inflammation in rheumatic mitral stenosis determine its clinical consequences. Atrial fibrillation is frequently encountered in mitral stenosis, though the independent role of chronic inflammation in determining atrial tachyarrhythmia occurrence in rheumatic heart disease has not been demonstrated previously. METHODS: Measurements of C-reactive protein (CRP) with a high sensitivity assay to detect chronic inflammation were performed in a homogenous group of 50 patients with rheumatic mitral stenosis, who were in sinus rhythm. Patients were questioned to exclude confounders of CRP elevation. The patients underwent a twenty-four-hour ambulatory ECG monitoring to check for asymptomatic atrial tachyarrhythmias and were in addition classified according to the presence of atrial tachyarrhythmias. RESULTS: Forty-four percent of patients showed a total of 100 episodes of atrial tachyarrhythmias where 63% of these episodes were paroxysmal atrial fibrillation. The CRP values in patients with tachyarrhythmias were significantly higher than in patients who remained in sinus rhythm (4.2 +/- 0.55 mg/L vs 1.99 +/- 0.36 mg/L, P < 0.001). A logistic regression analysis revealed only CRP levels and previous history of mitral valvuloplasty significantly determined tachyarrhythmia occurrence where age, left atrial volumes, mitral gradients had no statistically significant effect. CONCLUSIONS: Our data implicated that nearly half of the mitral stenosis patients who are in sinus rhythm develop asymptomatic tachyarrhythmias and the higher levels of CRP in these patients show the significant effect of persistent inflammation on arrhythmia occurrence.

Simvastatin may improve myocardial perfusion abnormality in slow coronary flow.

BACKGROUND: The slow coronary flow (SCF) phenomenon is a coronary microvascular disorder characterized by the delayed passage of contrast in the absence of obstructive epicardial coronary disease. Recent studies showed the possible role of endothelial dysfunction, diffuse atherosclerosis and inflammation in the pathogenesis of this phenomenon. We aimed to investigate the effect of statin on myocardial perfusion in patients with SCF. METHODS AND RESULTS: The study population consisted of 97 patients with SCF. Coronary flow patterns of the cases are determined by thrombolysis in myocardial infarction (TIMI) frame count method. Single-photon emission computed tomographic myocardial perfusion imaging studies and lipid parameters of the patients were obtained before and after 6 months of simvastatin treatment period. During the study, daily single dose of 40 mg simvastatin has been given to each subject. We found a significant positive correlation between mean TIMI frame count and basal reversibility score (r = 0.84, p = 0.0001). In addition, analysis of the reversibility scores demonstrates that simvastatin treatment has significantly improved the myocardial perfusion abnormality at the end of the follow-up period. CONCLUSION: Present findings allow us to conclude that simvastatin improved myocardial perfusion in patients with SCF.

Correlation of the myocardial performance index with plasma B-type natriuretic peptide levels in patients with mitral regurgitation.

OBJECTIVE: The Myocardial performance index (MPI) is an echocardiographic index of combined systolic and diastolic function, calculated as isovolumetric relaxation time plus isovolumetric contraction time divided by ejection time. The aim of this study was to define the correlation of the MPI with plasma B-type natriuretic peptide (BNP) levels and echocardiographic parameters in patients with chronic mitral regurgitation (MR). METHODS: About 33 patients with at least moderate MR of organic etiology were enrolled to the study. All patients undergone complete 2D and Doppler echocardiography. Plasma BNP levels were studied. RESULTS: BNP levels in NYHA classes I-III were 9.3 +/- 2.2 pg/ml, 61.3 +/- 12.2 pg/ml, and 199.6 +/- 55.2 pg/ml, respectively (I vs. II P < 0.001, I vs. III P < 0.001 and II vs. III P = 0.004). Myocardial performance index were 0.42 +/- 0.02, 0.49 +/- 0.02, and 0.52 +/- 0.03 in MR patients with NYHA I-III, respectively. MPI was significantly higher in patients with NYHA class III compared to NYHA I (P = 0.001) and NYHA II (P = 0.005). There were no correlations between MPI and left atrial diameter, MR jet area, MR index and systolic pulmonary artery pressure whereas left ventricle (LV) end-systolic volume (r = 0.38), LV end-diastolic volume (LVDV) (r = 0.40), LV ejection fraction (r = -0.59), NYHA class (r = 0.51) and plasma BNP levels (r = 0.67) were strongly correlated. Only independent variable affecting MPI was plasma BNP level (odds ratio [CI]: 2.18[0.002-0.098], P = 0.041). CONCLUSIONS: MPI is a powerful index in assessing the severity of left ventricular function and symptom severity in patients with MR. Plasma BNP is an independent predictor of MPI where both parameters assess combined systolic and diastolic LV function, effectively.