Baseline SYNTAX score and long-term outcome in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The SYNTAX score (SXscore) has emerged as a reproducible angiographic tool to quantify the extent of coronary artery disease based on the location and complexity of each lesion. The aim of this study was to evaluate whether the SXscore is an independent predictor of long-term cardiovascular outcomes in patients treated with primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI). METHODS: A total of 2993 patients with acute STEMI who underwent primary PCI were stratified into the 4 groups according to the SXscore quartiles; quartile 1(Q1, SXscore ≤ 9, n = 819), Q2 (9 < SXscore < 16, n = 715), Q3 (16 ≤ SXscore < 20, n = 710), and Q4 (SXscore ≥ 20, n = 749). RESULTS: There were significant differences among the quartiles with respect to age, basal creatinine and glucose levels, and the incidences of diabetes mellitus, Killip ≥2, and anemia. From Q1 to Q4, there were increasing rates of culprit left anterior descending lesion (P < .001), multivessel disease (P < .001), chronic total occlusion (P < .001), and proximal lesion localization (P < .001). At long-term follow-up, all-cause mortality, nonfatal myocardial infarction, stroke, rehospitalization due to heart failure, and the need of revascularization were significantly more frequent among the patients in the highest SXscore quartile. In multivariate analysis, after including the SXscore as a numerical variable into the model, every point of increase was determined as an independent predictor for long-term mortality (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = .008) and for overall major adverse cardiac events (MACEs; HR 1.02, 95% CI 1.01-1.04, P < .001). CONCLUSION: The SXscore is an independent predictor of both in-hospital and long-term mortality and MACE in patients with acute STEMI undergoing primary PCI.

Comparison of early and late clinical outcomes in patients >= 80 versus <80 years of age after successful primary angioplasty for ST segment elevation myocardial infarction.

OBJECTIVES: We aimed to compare the efficacy of primary percutaneous coronary intervention (p-PCI) in patients >=80 versus <80 years of age with ST-segment elevation myocardial infarction (STEMI). STUDY DESIGN: We retrospectively enrolled 2213 patients with acute STEMI. The patients were prospectively followed up for a median of 42 months. Early and late clinical outcomes were compared according to age. RESULTS: One-hundred and seventy-nine (8.1%) of the 2213 patients were aged >=80 years. Post-procedural TIMI grade 3 flow was significantly less frequent in the age >=80 years patients (82.1% vs. 91.1%, p<0.001). Rates of mortality (14.5% vs. 3.4%, p<0.001), heart failure (20.7% vs. 10.5%, p<0.001), major hemorrhage (9.5% vs. 3.3%, p<0.001), secondary VT/VF (10.1% vs. 4.2%, p=0.002) and atrial fibrillation (12.8% vs. 4.3%, p<0.001) during the early hospitalization period were significantly higher in the age >=80 years patient group. Overall rates of mortality (40% vs. 9.7%, p<0.001) and total stroke (5.6% vs. 1.1%, p=0.005) at long-term follow-up were also higher in the age >=80 years patient group. However, there was no difference between the two groups with respect to the reinfarction/revascularization rates. Analysis, using the Cox proportional hazards model, revealed that age >=80 to was an independent predictor of long-term mortality (hazard ratio 2.17, 95% CI 1.23-4.17, p=0.02). CONCLUSION: Age is an independent predictor of mortality after p-PCI for STEMI. Although it seems to improve early outcomes, the efficacy of p-PCI at long-term follow-up is limited in elderly patients.

Relation of the severity of contrast induced nephropathy to SYNTAX score and long term prognosis in patients treated with primary percutaneous coronary intervention.

BACKGROUND: SYNTAX score (SXscore) has been developed to assess the severity and complexity of coronary artery disease. The aim of this study was to evaluate whether baseline SXscore was associated with contrast induced nephropathy (CIN) after primary percutaneous coronary intervention (p-PCI) in patients with ST-elevation myocardial infarction (STEMI). Secondarily we aimed to investigate the relation of the severity of CIN to long term prognosis. METHODS: We retrospectively enrolled 1893 patients with STEMI treated by p-PCI. We prospectively followed up the patients for a mean duration of 45 months. The patients were grouped according to the development of no nephropathy (grade 0, n: 1634), mild nephropathy (grade 1, n: 153) or severe nephropathy (grade 2, n: 106). RESULTS: SXscore was significantly higher (19.4±5.9 vs 15.6±4.8, p<0.001) in patients with CIN (grades 1 and 2) compared to those without CIN. SXscore was higher in patients with grade 2 CIN compared to those with grade 1 CIN (18.5±5.7 vs 20.7±5.9, p<0.001). In the multivariate analysis, SXscore was identified as an independent predictor of CIN (for one unit increment, OR: 1.06, 95% CI: 1.01-1.14, p=0.006). At long-term follow-up, death (p<0.001), stroke (p=0.006), reinfarction (p=0.024) and permanent HD requirement (p<0.001) were most frequent in grade 2 nephropathy group. HD was associated with very high in-hospital (60%) and long-term (83.3%) mortality rates. CONCLUSIONS: SXscore is an independent predictor of development and severity of CIN after p-PCI. CIN is associated with poor prognosis during both early and late postinfarction period.

[Reshaping the left Judkins catheter for a right coronary angiogram in the anomalous aortic origin of the right coronary: killing two birds with one left Judkins]. / Sag koroner arter çikis anomalilerinde yeniden sekillendirilen sol Judkins kateter ile sag koroner anjiyografisi: Bir sol Judkins ile iki kus

OBJECTIVES: Selective cannulation of the right coronary artery (RCA) in the anomalous aortic origin of the RCA is technically difficult and challenging. In this study, we tested the success of RCA cannulation with a reshaped left Judkins catheter in cases of difficult selective cannulation. STUDY DESIGN: The study population consisted of 837 consecutive patients (456 male, 381 female) that were admitted to our hospital with stable angina pectoris and acute coronary syndrome between October 1 and December 31, 2011. In cases where RCA cannulation was difficult, the 10 centimeter section of the left Judkins proximal to the secondary curve was reshaped by hand to form an inward slope. The secondary curve angle was increased to approximately 100 degrees and the primary curve angle was adjusted to 120 degrees. Then, we attempted to perform selective RCA cannulation. RESULTS: In 49 of the 837 patients, selective RCA cannulation was unsuccessful with the right Judkins catheter. In 42 of these 49 (86%) cases, the RCA was cannulated with the reshaped left Judkins. We failed to cannulate the right coronary in two cases with downward angulation, one with upward angulation, one with high take-off origin, and one with anterior origin. A multipurpose, internal mammary artery, left Amplatz 1, and right Amplatz 1 catheter were used for cannulation in these cases, respectively. There was no angina, nor were there electrocardiographic or hemodynamic changes during the procedure. CONCLUSION: In cases where the selective cannulation of the RCA is difficult, using a reshaped left Judkins may be a successful and cost-effective method of selective cannulation.

Recurrent acute stent thrombosis due to allergic reaction secondary to clopidogrel therapy.

Despite significant benefits including mortality advantage demonstrated with antiplatelet therapy in large clinical trials, the occurrence of adverse ischemic events, including stent thrombosis after percutaneous coronary intervention has been the challenging and devastating complication. Clopidogrel as a monotherapy, or more common in combination with aspirin, represents a cornerstone of modern pharmacotherapy in the invasive era. Although vigilance in maintenance of this dual antiplatelet treatment is mandatory, obligatory cessation of one of these agents can be observed in rare circumstances of adverse events. We describe a patient who developed recurrent acute stent thrombosis associated with clopidogrel-induced allergic reaction and discuss our therapeutic considerations.

Extended septal myectomy for hypertrophic obstructive cardiomyopathy with anomalous insertion of chordae tendineae.

We present a case of hypertrophic cardiomyopathy with anomalous insertion of mitral valve chordae tendineae diagnosed with two-dimensional echocardiogram. A high gradient was found in left ventricular outflow tract (LVOT) obstruction, which was attributed to the fixed gradient caused by anomalous insertion of chordae tendineae in addition to the gradient of dynamic LVOT obstruction. The misinserted chordae tendineae were resected, and an extended septal myectomy was performed. Follow-up echocardiography showed reduction of the pressure gradient to less than 40 mm Hg in the LVOT, and the patient had no symptoms during the 1-year follow-up period.

QT duration and dispersion in patients with anomalous origins of coronary arteries.

BACKGROUND: Coronary artery anomalies have been reported to show various symptoms ranging from chest pain and dyspnea to cardio-respiratory arrest and sudden death. In this study, we attempted to assess the changes in QT interval duration and dispersion in anomalous origins of coronary arteries (AOCA). METHODS: Nineteen AOCA patients (mean age: 52 +/- 11 years) and 30 healthy control subjects (mean age: 50 +/- 12 years) were included in the study. Minimum and maximum corrected QT intervals, and corrected QT dispersion were calculated. The two groups were compared in terms of QT dispersion and QT duration. RESULTS: There was no difference between the two groups in terms of baseline demographic characteristics. Maximum corrected QT intervals (QTc max), minimum corrected QT intervals (QTc min), and corrected QT dispersion were higher in AOCA patients than controls (452 +/- 38 vs 411 +/- 25 ms [P = 0.0001], 402 +/- 31 vs 383 +/- 28 ms [P = 0.048], and 51 +/- 30 vs 28 +/- 12 ms [P = 0.001], respectively). CONCLUSION: In the patients with anomalous origins of coronary arteries, QT dispersion that is an indicator of sudden cardiac death and arrhythmias frequency increased. QTc max, QTc min, and corrected QT dispersion are higher in patients with anomalous origin of the coronary artery than in control subjects.

Use of PTFE-covered stent in acute myocardial infarction of aneurysmatic coronary artery.

Coronary artery aneurysms are reported between 0.1-4.9% in coronary angiographies. Vessel wall weakening, inflammation and endothelial damage play a role in their development. They may compromise the coronary flow and play a source for recurrent embolization of thrombus fragments. Here we report a patient with coronary artery aneurysm in left anterior descending artery with a critical thrombosed proximal segment and resulting in acute myocardial infarction. Coronary artery aneurysm is managed with polytetrafluoroethylene (PTFE) covered stent and proximal infarct related segment is treated with a bare metal stent. Coronary patency is provided without any obvious complication at the end of the procedure.

The role of tissue Doppler study in the assessment of left ventricular dysfunction in obesity.

PURPOSE: The purpose of this study was to investigate the potential utility of tissue Doppler echocardiography in the assessment of left ventricular systolic and diastolic function in the obese population. METHOD: 96 obese (48 male, 48 female) patients and 50 normal weight (25 male, 25 female) control subjects were enrolled. Obese patients were subgrouped into mild (25-29.9 kg/m2), moderate (30-34.9 kg/m2) and significant (> or =35 kg/m2) according to their body mass index (BMI). Left ventricular systolic and diastolic functions were evaluated by tissue Doppler imaging with conventional transthoracic echocardiography. Peak systolic velocity (Sm) of the lateral mitral annulus, the duration from electrocardiographic Q wave to Sm and early and late diastolic velocities (Em,Am) were recorded with tissue Doppler imaging. RESULTS: The ejection fraction and fractional shortening values were found to be increased in the mildly and moderately obese subjects. Left ventricular diameters were increased in all of the patients in the obesity group; however, relative wall thicknesses were similar to control subjects.The peak systolic velocities of the mitral lateral annular area (Sm) were lower in moderately and significantly obese subjects compared to the control subjects. None of the study patients had systolic dysfunction by conventional echocardiographic assessment while prevalence of diastolic dysfunction was significantly higher in the obese group of which the prevalence proportionally increased with BMI. Diastolic dysfunction was also more prevalent in the subjects with abdominal obesity which was determined by waist circumference (WC). CONCLUSION: The ejection phase indices were increased in mildly and moderately obese subjects. However, in significantly obese subjects they were similar to control subjects by conventional echocardiographic methods. Sm values of the moderately and significantly obese patients were significantly lower when measured by tissue Doppler imaging. Diastolic function was also shown to be impaired in the moderately and significantly obese subjects when measured by tissue Doppler imaging.

The frequency of angiotensin-converting enzyme genotype and left ventricular functions in the obese population.

The authors investigated the relationship between angiotensin-converting enzyme (ACE) genotype and left ventricular functions in an obese population and compared their findings with controls. Ninety-six obese patients and 50 controls were enrolled. Obesity was subgrouped into mild (body mass index [BMI] 25-29.9 kg/m(2)), moderate (BMI 30-34.9 kg/m(2)), and significant (BMI > or =35 kg/m(2)). Body fat distribution was categorized according to waist-to-hip ratio and waist circumference. Left ventricular systolic and diastolic functions were evaluated by echocardiography. ACE gene polymorphism was investigated by standard polymerase chain reaction, and frequency distributions were calculated for the subgroups. Systolic functional indices were found to be increased in mild and moderate obesity subgroups. The obese population had increased left ventricular diameters. None of the patients had systolic dysfunction, while diastolic dysfunction was significantly more common in the obese group; the frequency of diastolic dysfunction was proportionally increased with body mass index. Diastolic dysfunction was more common in persons with abdominal obesity. ACE DD genotype frequency was increased in moderately and significantly obese subgroups and also in all obese patients with diastolic dysfunction.

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report.

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.

Prognostic value of N-terminal pro-B-type natriuretic peptide in patients with active infective endocarditis.

Our aim was to determine whether N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) levels are valuable for predicting prognosis in patients with infective endocarditis (IE). We analyzed measured plasma NT-pro-BNP levels at admission in 45 patients with definite IE. The primary end point was early surgery or in-hospital death. The other data recorded were baseline clinical, echocardiographic, and laboratory parameters. Thirty patients underwent early surgery, and 9 died in hospital. Univariate analysis revealed that log NT-pro-BNP, cTnI > or =0.03 ng/ml, New York Heart Association functional class III to IV symptoms, left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and severe valvular regurgitation were associated with increased risk of reaching the primary end point. Cox proportional hazard regression analysis identified log NT-pro-BNP (hazard ratio 1.5; 95% confidence interval 1.2 to 1.9, p <0.001) as the only independent predictor of the primary end point. The log NT-pro-BNP cut-off value with the highest sensitivity (97%) and specificity (92%) for predicting primary end point was 7.2 (1,500 pg/ml). Patients with NT-pro-BNP level > or =1,500 pg/ml had significantly lower event-free survival than others. In conclusion, admission NT-pro-BNP is of prognostic value in patients with IE. The combination of admission NT-pro-BNP and cTnI levels appears to have even greater value for risk stratification in this patient group.

Aortic elastic properties in patients with hypertensive response to exercise.

BACKGROUND: The aim of this study was to evaluate whether there is a relationship between aortic elastic properties in patients with a suggestive response to treadmill exercise testing. METHODS AND RESULTS: The study group comprised 32 patients suggesting hypertensive response to exercise and 20 patients suggesting normal blood pressure response to treadmill exercise testing. Baseline demographic characteristics were similar in both groups. However, the mean aortic stiffness index of patients suggesting hypertensive response to treadmill exercise testing was significantly higher (4.8+/-1.26 vs 2.36+/-1.09; p=0.001) whereas aortic distensibility was significantly lower (12.82 +/-5.84 vs 22.64+/-14.54; p=0.001) than the control group. The aortic strain of patients with hypertensive response to exercise was lower than the control group (12+/-3% vs 19.2+/-5%, p<0.001). The left ventricular mass (LVM) of these patients was also higher than control group (206.5+/-46.3 vs 134.2+/-19.97; p=0.01). A negative correlation between LVM and distensibility was found (r=-0.64; p=0.001) well as a positive correlation between LVM and aortic stiffness index (r=0.51; p=0.004) in patients suggesting hypertensive response to exercise. Pressure--rate product was also found to be correlated with LVM (r=0.47; p=0.006). CONCLUSION: Elastic properties of the aorta may be impaired in subjects showing exaggerated blood pressure response to exercise long before clinically manifest hypertension, particularly if the LVM is increased.

Left atrial appendage functions in patients with severe rheumatic mitral regurgitation.

AIM: The left atrial appendage (LAA) function was evaluated in patients with severe rheumatic mitral regurgitation, having sinus rhythm or atrial fibrillation, by standard and tissue Doppler echocardiographic examinations. METHODS AND RESULTS: Sixty patients with rheumatic severe mitral regurgitation were enrolled. The patients (14 females and 6 males) having sinus rhythm were selected as group I and 20 patients (15 females and 5 males) with atrial fibrillation formed group II. 20 healthy subjects (15 female and 5 males) served as the control group (group III). In order to determine the LAA functions, LAA peak filling flow velocity (LAAPFV), LAA peak emptying flow velocity (LAAPEV) and percentage of LAA area change (LAAAC %) were measured. In the TDI records of the subjects with sinus rhythm, the first positive wave identical to the LAA late emptying wave (LEW) following the P-wave was accepted as LAA late systolic wave (LSW), and the second negative wave identical to the LAA late filling flow was accepted as late diastolic wave (LDW). In patients with atrial fibrillation, the positive wave was accepted as LAA late systolic wave (LSW), and the second negative wave identical to the LAA late filling flow was accepted as late diastolic wave (LDW). LAA outflow and inflow velocities were lower in the group having atrial fibrillation (P < 0.002, and P < 0.007, respectively). LAAAC% was also reduced in group II (P < 0.0001). The pulsed Doppler LSW and LDW velocities, measured with TDI method were found to be quite reduced in patients with AF (P: 0.002 and P: 0.001, respectively). The study parameters were statistically similar in patients with normal sinus rhythm and controls. CONCLUSION: In this study, we found that the LAA functions are impaired in patients with severe mitral regurgitation, having AF, whereas preserved in patients with normal sinus rhythm, compared to controls.

Mean platelet volume in patients with isolated coronary artery ectasia.

Coronary artery ectasia (CAE) is frequently considered to be an incidental angiographic finding; however, several reports have shown an association with myocardial ischemia and infarction. In this study, we aimed to evaluate the mean platelet volume (MPV), which is a marker of platelet reactivity, in patients with isolated CAE. In this study we investigated the platelet functions by MPV measurement in patients with isolated CAE. The study population consisted of 23 patients (17 males, 6 females) with isolated CAE (Group-I). Sex-age matched 30 patients (22 males, 8 females) with angiographically proven normal coronary arteries served as the control group (Group-II). Serum total cholesterol, HDL-C, LDL-C, triglyceride level, hemoglobin, white blood cell count, CRP, platelet count and MPV were compared in both groups. There was no significant difference between two groups in terms of age, gender, body mass index, blood pressure and heart rate. Serum total cholesterol, HDL-C, LDL-C, triglyceride level, hemoglobin, white blood cell count, platelet count were also similar in both groups. However, the MPV values of patients with isolated CAE were significantly higher than those of controls (P < 0.0001). In addition to that, CRP levels were found to be significantly higher in patients with isolated CAE (P < 0.002). Increased MPV may indicate the altered platelet reactivity and aggregation and thereby may be associated with ischemic events, observed in patients with isolated CAE.

Large mural vegetation attached to the left ventricular outflow tract: a case report.

We describe an unusual case of staphylococcal endocarditis with vegetation attached to the left ventricular outflow endocardium in a patient with chronic severe aortic regurgitation that was diagnosed by transthoracic echocardiography. There was no involvement of aortic valve endocardium confirmed by transthoracic echocardiography, transesophageal echocardiography, and macroscopically in the operation. This report confirms that chronic endocardial trauma may provide a fertile nidus for the development of bacterial vegetation.