Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis.

The treatment options for high risk acute pulmonary embolism (PE) patients with failed systemic thrombolytic treatment (STT) is limited. The clinical use of catheter directed thrombolysis with the EkoSonic Endovascular System (EKOS) in this population has not been evaluated before. Catheter directed thrombolysis is an effective treatment modality for high risk PE patients with failed STT. Thirteen consecutive patients with failed STT were included in the study. EKOS catheters were placed and tissue plasminogen activator (t-PA) in combination with unfractionated heparin were given. Clinical and echocardiographic properties of the patients were collected before EKOS, at the end of EKOS and during the follow-up visit 6 months after discharge. The duration of EKOS treatment was 21.8 ± 3.8 h and the total dose of tPA was 31.2 ± 15.3 mg. One patient who presented with cardiac arrest died and the clinical status of the remaining subjects improved significantly. Any hemorrhagic complication was not observed. EKOS resulted in significant improvement of right ventricular functions and decrease of systolic pulmonary artery pressure. During a follow-up period of 6 months none of the patients died or suffered recurrent PE. In addition, echocardiographic parameters or right ventricular function significantly got better compared to in-hospital measurements. EKOS is an effective treatment modality for high risk PE patients with failed STT and can be applied with very low hemorrhagic complications.

Myocardial performance is impaired in patients with branch retinal vein occlusion.

OBJECTIVE: To investigate whether the Tei index, which is an indicator of global myocardial function and an independent predictor of cardiac death, is increased in patients with branch retinal vein occlusion (BRVO). METHODS: The Tei index was used to evaluate myocardial performance, in addition to conventional echocardiographic evaluation of myocardial structural and functional changes, in patients with BRVO, patients with hypertension and healthy controls. RESULTS: Out of 36 patients with BRVO (18 female, 18 male; 17 hypertensive, 19 normotensive), 29 patients with hypertension (15 female, 14 male) and 28 healthy controls (15 female, 13 male), there were no significant between-group differences in age and sex. The mitral A wave was higher and mitral E/A ratio, mitral E wave and ejection time were lower, in patients with BRVO than in healthy controls. Mean Tei index was significantly higher in the BRVO group than in patients with hypertension or healthy controls. Compared with healthy controls, the Tei index was significantly higher in hypertensive and normotensive patients with BRVO. CONCLUSION: Myocardial performance is decreased in patients with BRVO, independent of whether or not they have hypertension.

A rare reason for pulmonary hypertension: primary sarcoma of the pulmonary artery.

Primary sarcoma of the pulmonary artery (PSPA) is an extremely rare tumor of the cardiovascular system. The prognosis is very poor. The clinical symptoms and imaging findings imitate those of pulmonary emboli, causing delays in diagnosis. In this case report, we describe a 73-year-old man with PSPA who initially was admitted with exertional shortness of breath. Transthoracic echocardiographic evaluation revealed 2 masses in the pulmonary artery causing pulmonary hypertension. The patient underwent operation, but he could not be weaned off cardiopulmonary bypass at the end of the operation and died. Pathologic examination of the masses revealed pulmonary sarcoma. Although this patient was admitted to our clinic only 2 weeks after the initial symptoms, he already had distal metastases.

Impaired aortic stiffness and pulse wave velocity in patients with branch retinal vein occlusion.

BACKGROUND: Aortic distensibility (AD) and pulse wave velocity (PWV) reflect arterial stiffness, which is linked to increased cardiovascular morbidity and mortality in different diseases such as atherosclerosis, hypertension, and diabetes mellitus, all of which are also common risk factors in patients with branch retinal vein occlusion (BRVO). In the present study, we aimed to determine whether arterial stiffness in different segments of the arterial tree is increased in patients with BRVO. METHODS: The study group consisted of 35 patients with BRVO (20 female, 15 male, mean age: 55.9+/-6.8) and the age-matched control groups consisted of 19 patients with hypertension (9 female, 10 male, mean age: 55.2+/7.6) and 17 healthy subjects (9 female, 8 male, mean age: 53.4+/-9.6). Radial artery PWV was measured using a Pulse Wave Sensor HDI system, which measures non-invasively the radial pulse-wave recording with computer analysis of the diastolic decay, and provides separate assessment of the large arterial elasticity index (LAEI) and small artery elasticity index (SAEI). Aortic strain and AD was determined echocardiographically based on the relationship between changes in aortic diameter and pressure with each cardiac pulse. Patients with diabetes mellitus or inflammatory BRVO, and control patients with any occlusive vascular eye disease, were excluded. The results of the three groups were compared. RESULTS: Compared to the subjects of the healthy control group, those with BRVO had lower LAEI (p<0.05). Both AD and aortic strain were significantly lower in the BRVO group than in both control groups (p<0.05 for both) and in the hypertensive control group than the healthy controls (p<0.05). The AD, LAEI and SAEI were positively correlated (p=0.021, r=0.307 and p=0.041, r=0.269 respectively). CONCLUSIONS: The results of this study show that the arterial stiffness indices (large arterial elasticity index and aortic distensibility) are abnormal in patients with BRVO compared to the healthy and hypertensive controls. Arterial stiffness may play a role in the onset or progression of BRVO. Further studies are needed to determine the exact role of AS in the pathogenesis of BRVO, and to reveal its value in predicting systemic morbidity and mortality in patients with BRVO.

Diffuse involvement of the heart and great vessels in primary cardiac lymphoma.

Primary cardiac lymphoma (PCL) is an extremely rare disorder. In this report, a 57-year-old male with diffuse large B-cell lymphoma involving the heart and great vessels is presented. Trans-thoracic echocardiography was the first modality used to establish the diagnosis. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showed diffuse increased metabolic activity of the heart walls and hypermetabolic lesions occupying cardiac chambers in some areas. The patient underwent systemic chemotherapy, and after 13 days, a marked regression of the tumour mass was evident based on echocardiographic examination. After completing six R-CHOP chemotherapy treatments, PET imaging was planned to control the residual mass, but the patient was intubated due to pneumonia that developed after the sixth chemotherapy session and subsequently died due to sepsis.

Effect of percutaneous transluminal coronary angioplasty on QT dispersion and heart rate variability parameters.

BACKGROUND: The aim of the study was to analyse parameters reflecting the sympathovagal control of ventricular depolarisation and repolarisation [heart rate variability (HRV) and QT interval dispersion (QTd)] in patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA), and determine whether HRV correlates with QT dispersion parameters. METHODS: The study consisted of 26 consecutive patients (16 men, 10 women) with single-vessel coronary artery disease (CAD) who underwent elective coronary angioplasty. HRV analyses of all subjects were obtained with the time- and frequency-domain methods. For frequency-domain analysis, low-frequency HRV (LF), high-frequency HRV (HF) and the LF:HF ratio were measured. For time-domain analysis, standard deviations of the normal-to-normal QRS intervals (SDNN) and square roots of the mean squared differences of successive N-N intervals (rMSSD) were obtained. QT intervals were also corrected for heart rate using the Bazett's formula, and the corrected QT interval dispersion (QTcd) was then calculated. All measurements (HRV parameters and QTcd) were made before and immediately after PTCA. RESULTS: QTcd was significantly decreased after PTCA (52.2 +/- 3.5 vs 42 +/- 3.9 ms). SDNN (94.1 +/- 22 vs 123.9 +/- 35.2 ms), rMSSD (43.7 +/- 20.1 vs 73.4 +/- 14.5 ms) and HF (51.1 +/- 48.8 vs 64.2 +/- 28.6 ms(2)) were significantly higher after PTCA, whereas LF (142 +/- 41.5 vs 157.2 +/- 25.9 ms(2)) and the ratio of LF:HF (3.3 +/- 1.9 vs 2.1 +/- 1.2) were significantly decreased after PTCA. We observed a significant negative correlation after PTCA between QTcd and LF (r = -0.87, p = 0.01) and between QTcd and the ratio of LF:HF (r = -056, p < 0.05). CONCLUSION: Among the patients with CAD undergoing PTCA, QTcd significantly decreased after PTCA, and negatively correlated with LF, the parameter reflecting the sympathetic system.

Aortic distensibility and coronary artery bypass graft patency.

BACKGROUND: Aortic distensibility is an elasticity index of the aorta, and reflects aortic stiffness. Coronary artery disease has been found to be substantially associated with increased aortic stiffness. In this study we aimed to retrospectively analyze the association of angiographically determined aortic distensibility with the patency rates of coronary bypass grafts METHODS: The study was conducted in the Cardiology department of the Applied Research Centre for Health of Uludag University. The coronary angiograms of 53 consecutive coronary bypass patients were analysed retrospectively. Aortic distensibility was calculated using the formula: 2 x (change in aortic diameter)/(diastolic aortic diameter) x (change in aortic pressure). The number of stenosed and patent bypass grafts and the patient characteristics like age, risk factors were noted. RESULTS: There were 44 male (83%) and 9 female (17%) cases. Eighteen cases had only one saphenous vein grafting. The number of cases with two, three and four saphenous grafting were 18, 11 and 1; respectively. In the control angiograms the number of cases with one, two, three and four saphenous vein graft obstruction were 15 (31.3%), 7 (14.6%), 1 (2.1%) and 1 (2.1%) respectively. The aortic distensibility did not differ in cases with and without saphenous graft occlusion (p > 0.05). Also left internal mammary artery (LIMA) graft patency was not related to the distensibility of the aorta (p > 0.05). We also evaluated the data for cut-off values of 50 and 70 mmHg of pulse pressure and did not see any significant difference between the groups in terms of saphenous or LIMA grafts. CONCLUSION: In this study we failed to show association of angiographically determined aortic distensibility with coronary bypass graft patency in consecutive 53 patients with coronary artery bypass graft surgery (CABG).

Small arterial elasticity predicts the extent of coronary artery disease: Relationship with serum uric acid.

BACKGROUND: Arterial elasticity has been previously linked to atherosclerotic vascular disease states. Serum uric acid level has been recently associated with increased arterial stiffness, but to what extent serum uric acid reflects angiographic coronary artery status and vessel compliance remains to be established. In this study we aimed to evaluate the association of arterial elasticity indexes, serum uric acid and the presence and extent of angiographic coronary artery disease (CAD) in patients with chronic stable angina. METHODS: One hundred and eight consecutive patients attending for elective coronary angiography were investigated. The severity of CAD was expressed using the Gensini score. Quantitative analysis of the arterial elasticity was performed by applanation tonometry. Serum uric acid was measured in all participants. Stepwise multiple linear regression analysis was used to identify the independent correlates of the Gensini score. RESULTS: After adjustment for age, gender, common cardiac risk factors and cardiovascular drugs, small artery elasticity index (SAEI) (p<0.001) and serum uric acid (p<0.001) were independently correlated with the severity of CAD. Stepwise multiple linear regression analysis was also used to identify independent correlates of the SAEI. Serum uric acid emerged as the only independent correlate of SAEI (p<0.001). CONCLUSIONS: SAEI independently reflects the extent of CAD in patients with chronic stable angina. This relationship is chiefly mediated by serum uric acid. Our data add to the growing evidence that serum uric acid may be a marker of arterial stiffness and atherosclerotic burden.

Resolution of a giant atrial thrombus following anticoagulation therapy.

We report on a patient in whom a giant thrombus in the left atrium was detected by transthoracic echocardiography. Anticoagulant theraphy was started. After two months of therapy, repeat echocardiography showed complete resolution of the thrombus. This case indicates that large and presumably organised thrombi may be treated with anticoagulant therapy.

[Association of microalbuminuria and fasting insulin levels with presence and severity of coronary artery disease in non-diabetic cases]. / Diyabetik olmayan olgularda mikroalbüminüri ve açlik insülin düzeyi ile koroner arter hastaligi varligi ve siddetinin iliskisi.

OBJECTIVE: In this study, we aimed to determine the relation of presence and severity of coronary artery disease with microalbuminuria, fasting insulin levels and the classical risk factors in non-diabetic patients. METHODS: We enrolled 100 non-diabetic patients that had an indication for coronary angiography. Group 1 consisted of 55 patients with coronary artery disease, and 45 patients without coronary artery disease were included in Group 2. The study was cross-sectional and case-controlled. In all patients 24-hour microalbuminuria, serum total, high density lipoprotein (HDL), low density lipoprotein (LDL) cholesterol and lipoprotein a, triglyceride, fasting blood sugar levels were obtained. Fasting insulin levels were determined and routine urinary tests were performed. Gensini scoring was done for determination of the severity of coronary artery disease. Statistical analysis was performed using unpaired t test, Mann-Whitney U test, Chi-square test, ROC analysis and multiple logistic regression analysis. RESULTS: Microalbuminuria levels (p<0.001), fasting insulin levels (p<0.001), mean age (p=0.01), pulse pressure (p=0.014), LDL cholesterol levels (p=0.004), lipoprotein a levels (p<0.001) were significantly higher and HDL cholesterol levels were significantly lower (p=0.015) in Group 1 compared to the Group 2. Male gender was more frequent in Group 1 (p<0.001). With cut-off values defined by ROC analysis microalbuminuria (18 microgr/min, sensitivity: 91%, specificity: 45%, area under the curve: 0.790, 95% CI 2.43-15.96, p<0.001) increased probability of coronary artery disease by 6.2-fold and fasting insulin level higher than 10 microIU/ml by 11 folds at multivariate logistic regression analysis. When the cases were evaluated according to the Gensini scoring there was a significant association of coronary artery disease and microalbuminuria (r=0.52, p<0.001). CONCLUSION: We concluded that in non-diabetic cases microalbuminuria and increased fasting insulin levels were predictors of presence and the severity of coronary artery disease and can be suggested as risk factors.

Mitral valve thrombosis and infective endocarditis in a patient with prothrombin mutation.

This report deals with a 25-year-old female patient, who was admitted to a medical centre with complaints of fatigue and arthralgia. A non-homogeneous mass originating from the posterior papillary muscle and reaching the posterior and anterior cusps of the mitral valve was evident on the patient's echocardiogram. Her intractable fever, despite adequate antibiotic therapy, led us to consult with the cardiac surgeons. A mitral valve replacement was performed on the 8th day of admission. The pathological examination of the mitral valve and the vegetative lesion revealed the presence of organized thrombus and infective endocarditis. The patient had a history of oral contraceptive use for one year and at genetic examination we detected a heterozygous prothrombin mutation (G20210A). The association of infective endocarditis with native mitral valvular thrombosis in a case with prothrombin mutation and history of oral contraceptive use encouraged us to share our experience with our colleagues.

Lack of association of heart rate variability parameters with head-up tilt-test responses in patients with syncope.

BACKGROUND: Neurocardiogenic syncope is the most common type of syncope. Head-up tilt testing is the investigation of choice for diagnosis of patients with neurocardiogenic syncope. In this study, we aimed to findout any association between heart rate variability parameters and type of tilt-test response in patients with syncope. METHODS AND RESULTS: Forty-nine cases with unexplained syncopal attacks were enrolled into our study and were grouped according to the tilt-test responses. Tilt test was performed in all patients after excluding other causes of syncope. In case of a negative basal tilt-testing, pharmacological tilt testing was performed after 30 min of 5 mg sublingual isosorbide dinitrate. Holter monitoring was done from the beginning of tilt testing upto two hours post-procedure. The heart rate variability parameters analyzed were the mean of all coupling intervals between normal beats, the standard deviation about the mean of all coupling intervals between normal beats, the mean of all 5-min standard deviations of mean of all coupling intervals between normal beats, the proportion of adjacent normal R-R intervals differing by > 50 ms, the root mean square of the difference between successive RRs, and the standard deviation of 5-min mean of all coupling intervals between normal beats and ratio between low and high frequencies. CONCLUSIONS: In 35 patients, the tilt-test was positive, 16 were cardioinhibitor type (Group 1), four cases had a vasodepressor type response (Group 2) and 15 were mixed type (Group 3). Fourteen patients had a negative test result. The heart rate variability measures did not significantly differ among the study groups. The heart rate variability measures were compared between the tilt-test negative (Group 4) and the tilt-test positive groups (Groups 1, 2 and 3) and no statistically significant difference was found.