The association between CHA2DS2-VASc score and aortic valve sclerosis.

BACKGROUND: Antithrombotic therapy in atrial fibrillation is generally managed with the CHA2DS2-VASc score. Aortic valve sclerosis (AVS) is a focal thickening of the aortic valve without a restriction of motion. AVS is related to several cardiovascular risk factors. Our study was performed to evaluate whether the presence of AVS was associated with the CHA2DS2-VASc score. METHODS: This cross-sectional, observational study comprised 411 patients with AVS grades 1-3 [AVS (+)] and 102 patients with AVS grade 0 [AVS (-)]. We compared CHA2DS2-VASc scores between the AVS (+) and AVS (-) groups. RESULTS: We determined that the AVS (+) group had a higher CHA2DS2-VASc score than the AVS (-) group [3 (0-8) vs 1 (0-4), p < 0.001) ]. CONCLUSIONS: In our study, the CHA2DS2-VASc score was found to be higher in patients with AVS than in those without AVS. AVS may predict cardiovascular risk in the general population.

3-Dimensional Images of Mitral Annulus Perforation: An Alien's Mouth.

In this clinical vignette, we describe a case of a patient with windsock-like posterior mitral annulus perforation at the site of annular calcification caused by infective endocarditis. Three-dimensional transesophageal images of the perforation resembling an "alien's mouth" are very striking for how 3-dimensional imaging can improve visualization of anatomy of the heart. (Level of Difficulty: Intermediate.).

An Electrocardiographic Clue for Pseudo-myocardial Infarction Due to Arterial Pulse-tapping Artifact: Aslanger's Sign.

Many factors and technical problems may alter the interpretation of electrocardiograms (ECGs). Infrequently, an artifact is considered to be the cause of ST-segment elevation, especially in asymptomatic patients. An important difference between true ST-segment elevation attributable to myocardial infarction and an artifact is that the baseline elevation in an artifact may begin before or after the onset of the QRS complex. When one encounters an abnormal ECG that exhibits suspicious wave contours and possibly only one completely normal limb lead, the diagnosis of arterial pulse artifact should be considered.

Transcatheter Self-Expandable Aortic Valve (Portico) Implantation in a Patient with Previous Mitral Valve Replacement: A Case Report.

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or who are unsuitable candidates for open-heart surgery. However, concerns exist over treating patients who have undergone previous mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a case in which a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement was successfully treated with TAVI using a Portico valve, which is under-researched.

Percutaneous left atrial appendage closure in a patient with haemophilia and atrial fibrillation: a case report.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is a major cause of embolic stroke. In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. Left atrial appendage (LAA) closure is an emerging option in AF patients who are not eligible for oral anticoagulation therapy because of contraindications or high bleeding risk. CASE SUMMARY: A 67-year-old man with permanent AF and haemophilia was referred for further evaluation of our cardiology clinic by his primary haematologist. The CHA2DS2-VASc score was estimated to be 3 and the HAS-BLED score was 3. Due to high risk of bleeding, we decided to perform percutaneous LAA closure instead of oral anticoagulation. Pre-procedural cardiac computerized tomography angiography and transoesophageal echocardiography were performed for measurements of LAA dimensions and exclude LAA thrombus. Percutaneous LAA occlusion was performed using a 28-mm AmplatzerTM AmuletTM device. The final result was excellent without significant residual leak, pericardial effusion, and embolic complication. Clopidogrel 75 mg/day and aspirin 81 mg/day for 1 month with adequate FVIII prophylaxis and then only aspirin 81 mg/day for 2 months were recommended. No antiplatelet was given after 3 months. The patient did not report any thrombotic or haemorrhagic adverse events and there were no complications related to implanted device after 1 year of follow-up. DISCUSSION: In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. In this report, we present a case of percutaneous LAA occlusion using AmplatzerTM AmuletTM device in a patient who has haemophilia and permanent AF. LAA closure has the potential to be more cost effective as compared to oral anticoagulation therapy due to lesser necessity of clotting factor infusion.

Can hemodialysis change QRS axis in patients without cardiovascular disease?

OBJECTIVE: Due to rapid changes in volume and electrolyte concentration during hemodialysis (HD), some electrocardiographic (ECG) changes or arrhythmias can be seen. The aim of this study was to assess ECG QRS axis changes and other ECG parameters after HD in patients with end-stage renal disease (ESRD). METHODS: A total of 46 patients (65% male, mean age 52±15 years) with a sinus rhythm and without cardiovascular disease who were undergoing chronic HD treatment were included to the study. Blood samples, 12-lead electrocardiograms, and echocardiograms were recorded immediately before and at the end of an HD session. The QRS axis and other electrocardiographic, echocardiographic, electrolyte parameter, and volume changes were analyzed. RESULTS: The serum urea, creatinine, potassium, and B-type natriuretic peptide concentrations significantly decreased after HD, and the serum calcium levels significantly increased after HD. Body weight significantly decreased after HD. There was no significant difference in the QRS duration, PR interval, P-wave axis, QRS axis, or QT and QTc interval following HD. Based on a comparison of variables according to the any QRS axis change after HD treatment, there was no significant difference in biochemical values, HD time, ultrafiltration volume, left ventricular ejection fraction, or other echocardiographic findings. CONCLUSION: ESRD and HD are complex and dynamic processes, and the change in the QRS axis is rarely emphasized in these patients. In our study, there was no significant change in the QRS axis with HD in patients without cardiovascular disease.

A new risk scoring model for prediction of poor coronary collateral circulation in acute non-ST-elevation myocardial infarction.

BACKGROUND: We aimed to investigate the clinical features associated with development of coronary collateral circulation (CCC) in patients with acute non-ST-elevation myocardial infarction (NSTEMI) and to develop a scoring model for predicting poor collateralization at hospital admission. METHODS: The study enrolled 224 consecutive patients with NSTEMI admitted to our coronary care unit. Patients were divided into poor (grade 0 and 1) and good (grade 2 and 3) CCC groups. RESULTS: In logistic regression analysis, presence of diabetes mellitus, total white blood cell (WBC) and neutrophil counts and neutrophil to lymphocyte ratio (NLR) were found as independent positive predictors of poor CCC, whereas older age (≥ 70 years) emerged as a negative indicator. The final scoring model was based on 5 variables which were significant at p < 0.05 level following multivariate analysis. Presence of diabetes mellitus, and elevated total WBC (≥ 7.85 × 103/µL) and neutrophil counts (≥ 6.25 × 103/µL) were assigned with 2 points; high NLR (≥ 4.5) with 1 point and older age (≥ 70 years old) with -1 point. Among 30 patients with risk score ≤ 1, 29 had good CCC (with a 97% negative predictive value). On the other hand, 139 patients had risk score ≥ 4; out of whom, 130 (with a 93.5% positive predictive value) had poor collateralization. Sensitivity and specificity of the model in predicting poor collateralization in patients with scores ≤ 1 and ≥ 4 were 99.2% (130/131) and +76.3 (29/38), respectively. CONCLUSIONS: This study represents the first prediction model for degree of coronary collateralization in patients with acute NSTEMI.

Increased mean platelet volume in patients with infective endocarditis and embolic events.

BACKGROUND: Platelet activation appears to play an important role in thromboembolic complications of infective endocarditis (IE). Mean platelet volume (MPV) is a potentially useful marker of platelet activity and a quick and easy determinant of thrombotic risk. Hence the aim of this study was to investigate the baseline platelet volume indices (MPV and platelet distribution width [PDW]) in IE patients who developed embolic events in the follow-up period and who did not. METHODS: The study group consisted of 76 consecutive patients (female: 55, male: 21, mean age: 26 years old, ranged: 8-64 years) with definite IE according to Duke Criteria. Thirty four healthy subjects, who were age and gender adjusted, served as the control group. The mean duration of hospital stay was 44 days. RESULTS: Among the IE patients, 13 (13/76, 17.1%) had major embolic events. Significantly larger vegetations were observed in patients with embolic events as compared to non-embolic group (1.4 vs. 1.0 cm, p = 0.03). MPV at hospital admission was higher in patients who had embolic events in the follow-up period compared to both those who did not and the control subjects (10.62 ± 1.13 vs. 9.25 ± 0.97 and 8.93 ± 0.82 fL, p < 0.001, respectively). Similarly, the patients with embolic events had increased PDW compared to the non-embolic ones and the control group (16.31 ± 2.42 vs. 14.35 ± 1.97 and 14.04 ± 1.82%, p < 0.001, respectively). CONCLUSIONS: The present study demonstrated that IE patients with embolic events had increased MPV and PDW values, compared to non-embolics. Future prospective studies with standardized measurements may clarify the clinical role of platelet volume indices in thrombo-embolic complications of IE.

Increased mean platelet volume in rheumatic mitral stenosis: assessment of clinical and echocardiographic determinants.

BACKGROUND AND AIM: The aim of this study was to investigate mean platelet volume (MPV) in patients with rheumatic mitral stenosis (RMS) and to define the determinants of a possible platelet activation reflected as platelet volume enlargement. METHODS: Peripheral venous plasma value of MPV was measured in 84 consecutive patients (16 men, 68 women; mean age ± SD = 44 ± 13 years) with RMS who had no left atrial thrombus by transoesophageal echocardiography. The control group consisted of 32 healthy subjects (nine men, 23 women; mean age ± SD = 38 ± 7 years). RESULTS: The patients had significantly higher MPV values (mean ± SD = 10.07 ± 0.58 fL) compared to the healthy subjects (mean ± SD = 8.15 ± 0.60 fL, p < 0.001). Among many clinical and echocardiographic variables, left atrial spontaneous echo contrast-positivity (beta = 0.426, p < 0.001) and severe mitral regurgitation (beta = 0.577, p < 0.001) appeared as significant predictors of platelet enlargement in RMS in multiple linear regression analysis. CONCLUSIONS: Patients with RMS have increased platelet activity reflected as elevated MPV; and the coexistence of severe mitral regurgitation and presence of left atrial spontaneous echo contrast are determinants of this increment.