Negative effects of acute sleep deprivation on left ventricular functions and cardiac repolarization in healthy young adults.

BACKGROUND: Sleep deprivation (SD) is associated with an increased incidence of adverse cardiovascular events, we aimed to determine the impact of acute SD on structural and functional alterations of the left ventricle (LV) and on electrocardiogram (ECG) markers including T wave peak-to-end interval (TpTe), QT interval, and TpTe/QT ratio in healthy subjects after a night of SD. METHODS: The study population consisted of 40 healthy young adults (19 males, 21 females; mean age: 28.2 ± 3.86 years). Echocardiographic images and ECGs were obtained from the participants after a night of regular sleep (RS) and SD. The average sleep time of the subjects was 6.67 ± 1.76 hours during RS and 1.25 ± 0.74 hours during a night of SD. RESULTS: The myocardial performance index, isovolumic relaxation time, and deceleration time values were significantly higher after SD. In addition, the corrected TpTe interval, corrected QT interval (QTc) max, and TpTe/QT ratio were significantly increased after a night of SD when compared with a night of RS (78.5 ± 6.8 ms vs 70.7 ± 7.6 ms, P < 0.001; 407.5 ± 18.6 ms vs 395.07 ± 21.3 ms, P = 0.001; and 0.189 ± 0.014 ms vs 0. 0.179 ± 0.016 ms, P < 0.001, respectively). However, subjects had similar QTp interval values (defined as beginning of the QRS complex to peak of the T wave) after a night of SD as a night of RS (294.6 ± 19.0 vs 291.9 ± 18.5, P = 233). CONCLUSION: Our crossover study revealed the presence of subclinical LV diastolic functional changes and increased QT intervals, TpTe intervals, and TpTe/QT ratios in healthy young adults after one night SD. Therefore, the increased QT interval occurred secondary to the increased TpTe interval in this population.

[Evaluation of subclinical atherosclerosis in chronic sinusitis patients]. / Kronik sinüzitli hastalarda subklinik aterosklerozun degerlendirilmesi.

OBJECTIVE: This study aimed to assess the impact of chronic sinusitis (CS) on carotid-intima-media thickness (CIMT), a marker of early atherosclerotic changes in the arterial bed. METHODS: The study included 50 patients with CS (25 male, 25 female, mean age 26.6 ± 5.34 years), and 50 healthy subjects (25 male, 25 female, mean age 25.8 ± 4.76 years), aged 18 to 35 years without atherosclerotic risk factors, normal body mass index and normal metabolic parameters. CIMT was measured in all patients by ultrasonography. CS was confirmed by medical history and computed tomography scan of the paranasal cavities. RESULTS: No significant difference existed between the groups in terms of age, sex, body mass index (BMI), waist circumference, plasma creatinine, glucose, low-density lipoprotein (LDL), high-density lipoprotein (HDL) cholesterol values (p>0.05). However, mean values of CIMT (mm) were significantly greater in CS patients than in healthy subjects (0.51 ± 0.09 vs. 0.40 ± 0.07, p<0.001). Duration of CS disease was 6.0 (3.0-13.0) years. Significant correlation was found between CIMT mean values and age, BMI, waist circumference, HDL and LDL-cholesterol values and duration of CS (r=0.413; p<0.001, r=0.353; p<0.001, r=0.355; p<0.001, r=-0.266; p=0.007, r=0.327; p<0.001 and r=0.425; p=0.002 respectively). Multiple linear regression analysis revealed that waist circumference, HDL and LDL-cholesterol and duration disease of CS were independent predictors of CIMT (ß=0.523; p=0.001, ß=-0.176; p=0.045, ß=0.297; p=0.002, and ß=0.436; p<0.001, respectively). CONCLUSION: Our cross-sectional study revealed the presence of a negative effect of CS on the atherosclerotic process. Therefore, it is believed that effective treatment of CS may be beneficial in slowing the process of atherosclerosis.

Effect of smoking on Tp-e interval, Tp-e/QT and Tp-e/QTc ratios as indices of ventricular arrhythmogenesis.

BACKGROUND: Smoking may lead to ventricular arrhythmias and sudden cardiac death via altering ventricular recovery time dispersion indices such as QT interval and QT dispersion (QTd). The Tp-e/QT and Tp-e/QTc ratios are also known as predictors of ventricular arrhythmogenesis. The aim of this study was to evaluate the relationship between cigarette smoking and ventricular repolarisation dispersion using these novel electrocardiographic parameters. METHODS: One hundred and twenty-one chronic smokers and 70 age- and sex-matched non-smoker controls were included in our study. The Tp-e interval and Tp-e/QT ratio were measured by 12-lead electrocardiogram, and corrected for heart rate. RESULTS: QTd (34.2 ± 8.4, 27.2 ± 10.4, P<0.001) and corrected QTd (37.3 ± 8.9, 29.8 ± 11.2, P<0.001) were significantly increased in the smokers compared to the non-smoker control group. The Tp-e interval (76.5 ± 6.3, 70.3 ± 6.8, P<0.001), cTp-e interval (83.5 ± 8.0, 77.1 ± 8.7, P<0.001), Tp-e/QT (0.20 ± 0.03, 0.19 ± 0.02, P<0.001) and Tp-e/QTc ratios (0.19 ± 0.02, 0.17 ± 0.02, P<0.001) were increased in the patient group when compared to the controls. Significant positive correlations were also found between the level of smoking with the cTp-e interval (r=0.836, P<0.001), and Tp-e/QT (r=0.714, P<0.001) and Tp-e/QTc ratios (r=0.448, P<0.001). CONCLUSION: We found in our study that cTp-e interval, Tp-e/QT and Tp-e/QTc ratios were increased in smokers and significantly correlated to the amount of smoking.

[Long QT-induced ventricular tachycardia associated with Takotsubo cardiomyopathy]. / Takotsubo sendromu ile iliskili uzun QT'nin tetikledigi ventrikül tasikardisi.

Takotsubo cardiomyopathy (TC) is a syndrome characterized by transient left ventricular apical ballooning associated with electrocardiogram changes and mimicking acute myocardial infarction in patients without significant coronary disease on angiography. We report an unusual case of a patient who presented with TC associated with long-QT syndrome-induced ventricular tachycardia. QT interval prolongation was normalized and ventricular tachycardias were stopped within the same day with metoprolol treatment.

Neutrophil to lymphocyte ratio predicts poor functional capacity in patients with heart failure.

OBJECTIVES: We aimed to assess the relationship between neutrophil to lymphocyte ratio (N/L ratio) and functional capacity (FC) of patients with compensated heart failure (CHF). STUDY DESIGN: A total of 94 consecutive CHF patients and age-gender matched 70 subjects with normal echocardiographic examination were enrolled. Peripheral venous blood samples were drawn before echocardiography examination and treadmill test in all study population. The treadmill test based on modified Bruce protocol was used to determine the functional status of CHF patients. Poor FC was defined as <5 metabolic equivalant (MET) in the exercise test. Afterwards, patients with CHF were divided into two groups with respect to the top and bottom 3 of the N/L ratio. RESULTS: FC (3.2 ± 2.05 MET vs. 6.1 ± 2.04 MET, p<0.001), ejection fraction (%31.5 ± 7.64 vs. %34.8 ± 6.82, p=0.028) were found to be lower and N-terminal pro-brain natriuretic peptide (NT-proBNP) level (3360 ± 2742 pg/dl vs. 1613 ± 1334 pg/dl, p<0.001) pulmonary artery pressure (46.3 ± 11.50 mmHg vs. 41.5 ± 9.45 mmHg, p=0.049), left atrial diameters (4.6 ± 0.52 cm vs. 4.3 ± 0.43 cm, p=0.005), E/Ea ratio (12.2 ± 4.37 vs. 9.2 ± 3.20, p<0.001) were found to be higher in CHF patients with an N/L ratio >3 than with an N/L ratio <3. The N/L ratio, and log-NT-proBNP level were determined to be a predictive factor of poor FC (odds ratio [OR]=3.085, 95% confidence interval [CI]= 1.520-6.260, p=0.002 and OR=1.585, 95% CI=1.201-2.091, p=0.001, respectively). A cut-off point of 2.74 for the N/L ratio had 79.4% sensitivity and 80% specificity in predicting poor FC. CONCLUSION: N/L ratio can be used to predict poor FC in patients with CHF.

Rapid recovery from acute myocarditis under levosimendan treatment: report of two cases.

WHAT IS KNOWN AND OBJECTIVES: Acute viral myocarditis (AVM) is an inflammatory heart disease that may lead to acute heart failure caused by cardiomyocyte loss. AVM may result in fatal outcome due to hemodynamic compromise. There is no specific treatment for AVM. Treatment is generally same as the treatment of conventional heart failure. Levosimendan is a new molecule with inotropic and vasodilator effect and is widely used for acute decompensated heart failure. DETAILS OF THE CASES: Case 1: A 48-years-old, previously healthy male patient admitted to our clinic with complaints of acute onset of rest dyspnea and orthopnea, started the day before. Cardiac chambers were enlarged on echocardiography with global hypokinesia and ejection fraction (EF) was 25%. The patient was diagnosed as AVM complicated with decompensated heart failure. Continuous infusion of 0·2 µg/kg/min levosimendan for 24 h with treatment of conventional heart failure. Echocardiographic follow-up revealed a rapid improvement in left ventricular EF (50%) after 24 h. Case 2: A 33-years-old male patient admitted to our clinic with new onset shortness of breath and palpitation complaints. Echocardiography revealed enlarged left heart cavities with global hypocinesia (EF was 25%). The patient was diagnosed as AVM complicated with decompensated heart failure. Continuous infusion of 0·2 µg/kg/min levosimendan for 24 h with treatment of conventional heart failure. Echocardiography revealed dramatic improvement of left ventricular systolic function (EF = 55%) 24 h later. WHAT IS NEW AND CONCLUSION: To our knowledge, there is no report or study on levosimendan therapy for AVM in humans to date. Herein, we share two cases that revealed dramatic improvement in the myocardial function with levosimendan usage during the early phase of AVM.

Twin circumflex arteries with left sinus of valsalva origin: a case report.

Coronary artery anomalies are not uncommon. The importance of coronary anomalies varies from unimportant to life threatening. Herein, we report for the first time twin circumflex coronary arteries originating separately from the left sinus of Valsalva.

[Closure of secundum atrial septal defects by the Amplatzer occluder device]. / Sekundum atriyal septal defektlerin Amplatzer cihazi ile kapatilmasi

OBJECTIVES: Percutaneous closure of secundum atrial septal defects (ASD) has become an important alternative treatment to surgery. We evaluated our clinical experience with, and short-term results of transcatheter closure of ASDs with the Amplatzer septal occluder in adult patients. STUDY DESIGN: The study included 52 patients (36 women, 16 men; mean age 33±14 years; range 14 to 69 years) who underwent transcatheter ASD closure with the Amplatzer occluder device. The mean ASD diameter measured by transesophageal echocardiography was 19.5±5.7 mm and the mean device diameter was 24.5±5.7 mm. All the patients were assessed clinically and echocardiographically one month after the procedure. RESULTS: Transcatheter ASD closure was successfully performed in 48 patients (92.3%) and failed in four patients (7.7%). Echocardiographic controls showed significant decreases in tricuspid regurgitation, right ventricular dilatation, and pulmonary artery pressure (p=0.003, p=0.026, and p=0.0001, respectively). Functional capacity of the patients also showed significant improvements (p=0.0001). After implantation, residual shunts were detected in four patients, all of which disappeared one month after the procedure. Major complications were seen in two patients. One patient developed ventricular fibrillation immediately after the procedure due to device embolization. One patient with left ventricular dysfunction developed device thrombosis due to cessation of dual antiplatelet therapy, which was successfully treated by anticoagulation therapy. Arrhythmia was not observed in any patient. CONCLUSION: Percutaneous closure of secundum ASDs with the Amplatzer occluder device is a safe and effective procedure with a high success rate.

Complete thrombus resolution with tirofiban in obstructive mechanical prosthetic mitral valve thrombosis.

Mechanical prosthetic valve thrombosis is a rare but life threatening complication after valve replacement. Although the traditional treatment of prosthetic valve thrombosis is surgery, recently thrombolytic therapy has been accepted as an alternative treatment. We describe for the first time prosthetic valve obstructive thrombus that was resolved by administering tirofiban (glycoprotein IIb/IIIa receptor antagonist) in a patient using warfarin with an international normalized ratio of 3.4. In our view, although this issue need to be clarified in further studies, tirofiban seems to be an alternative therapy especially in patients who have high risk of bleeding or surgical complication.

Prognostic value of pleural effusion, CA-125 and NT-proBNP in patients with acute decompensated heart failure.

BACKGROUND: Acute decompensated heart failure (HF) is a serious complication associated with significant morbidity and mortality. The CA-125 and NT-proBNP levels have been shown in some studies to predict the outcome, however, the prognostic value of other simple clinical parameters such as pleural effusion has not been established yet. AIM: To assess the prognostic value of pleural effusion regarding in-hospital and 6-month follow-up outcome in patients with acute decompensated HF and the relationship between pleural effusion and CA-125 and NT-proBNP levels. METHODS AND RESULTS: The CA-125 and NT-proBNP levels were measured at baseline and the presence of pleural effusion was examined on chest radiograms. One hundred patients were prospectively followed until the occurrence of cardiac death, defined as death from worsening HF or sudden cardiac death, or completion of follow-up period. There were 27 deaths over the course of 6 months of follow-up. An insignificant trend towards higher values of CA-125 was found in patients with pleural effusion. Univariate Cox regression analysis showed that there was no relationship between pleural effusion and in-hospital outcome as well as mortality during 6-month follow-up. The CA-125 and NT-proBNP levels predicted mortality. Multivariate Cox regression analysis showed that only CA-125 was an independent predictor of the 6-month outcome (RR: 1.2; 1.04-1.4; p = 0.001). CONCLUSIONS: In patients with acute decompensated HF, accompanying pleural effusion did not predict mortality or rehospitalisation during the 6-month follow-up. The increased CA-125 level was found to be an independent predictor of poor outcome, irrespective of pleural effusion.

[Echocardiography-guided pericardiocentesis with the apical approach]. / Ekokardiyografi rehberliginde apikal yaklasimla perikardiyosentez.

OBJECTIVES: We aimed to evaluate our experience with echocardiography-guided pericardiocentesis with the apical approach for pericardial effusions. STUDY DESIGN: We evaluated 32 pericardiocenteses performed under echocardiography guidance and with the apical approach in 29 patients (15 men, 14 women; mean age 49 years; range 18 to 72 years). Indications were diagnostic purpose, pericardial tamponade, or symptomatic pericardial effusion. Procedural success, the amount of drainage, and complications were assessed. RESULTS: Common causes of pericardial effusion were malignancy (n=6), postpericardiotomy syndrome (n=5), idiopathic (n=5), chronic renal disease (n=4), and myocardial infarction (n=3). The amount of drainage was 120 ml to 2,200 ml and the duration of pericardial catheter placement in the pericardial space was 24 to 144 hours. Mortality did not occur. Echocardiographic control showed residual effusion in the lateral wall in one case, which required repositioning of the pericardial catheter for complete removal. The procedure failed in one patient due to insufficient drainage caused by multiple septations and fibrinous fluid in the pericardial space. The success rate of the procedures was 96.9%. Four cases developed hemopneumothorax requiring tube drainage, vasovagal reaction, nonsustained ventricular tachycardia, and frequent ventricular extrasystoles, respectively. Apical puncture was repeated in two cases due to erroneous left ventricular puncture and pleural catheter placement, respectively. CONCLUSION: Echocardiography-guided pericardiocentesis with the apical approach is readily performed bedside without the need for catheterization laboratory, with a high success rate and low complication rate. It should be considered especially in cases in which anterior pericardial collection is more prominent where it will reduce unnecessary surgical interventions.

Evaluation of early subclinical cardiotoxicity of chemotherapy in breast cancer.

OBJECTIVE: Cardiac effects of chemotherapy are usually recognized after clinical symptom or sign occurrence in patients with breast cancer. In this study, we aimed to determine the potential subclinical cardiotoxic effects of chemotherapy that were given lower dosage than well known cardiac safety dosage limits in patients with breast cancer during early period. METHODS: Fifty-one patients consecutively enrolled to this prospective cohort study. All patients were diagnosed as breast cancer at oncology hospital in University of Gaziantep. Before chemotherapy, all of the patients underwent to detailed ECG and echocardiography (ECHO) examinations. After 6 months, detailed ECG and ECHO examinations were repeated and compared with baseline values. Statistical analysis was performed using Shapiro-Wilk tests, Student t-test and Spearman correlation test. RESULTS: The average age of patients was 51 and one was male. Statistically significant decrease in ejection fraction was found after treatment (62.3%±3.3 and 59.9%±5.9, p=0.002). Evaluation of diastolic parameters; significant increase in the transmitral A flow velocity and significant decrease of E/A ratio were observed on Doppler ECHO analysis (77.4±19.1 cm/sec versus 86±18 cm/sec, p<0.001; 1.01±0.3 versus 0.9±0.2, p=0.03, respectively). On tissue Doppler analysis we observed that significant reduction in the value of E' and significantly increase E/E' ratio were present (12.5±3.6 cm/sec versus 10.7±2.9 cm/sec, p=0.001; 6.6±2.9 versus 7.7±3.3, p=0.04, respectively). CONCLUSION: Chemotherapy has detrimental subclinical effect on both of systolic and diastolic function in early six months period despite the prescription of lower dosage of chemotherapy than well-known cardiac safety dosage limits. Tissue Doppler imaging may be more sensitive than ECG, conventional ECHO and Doppler for determining the subclinical cardiac damage.

The usefulness of plateletcrit to predict cardiac syndrome X in patients with normal coronary angiogram.

INTRODUCTION: Cardiac syndrome X (CSX) is a clinical entity defined as the triad of typical angina pectoris on exercise, electrocardiographic or metabolic findings of ischemia and normal epicardial coronary arteries. Platelets, whose amount in the blood is indicated with plateletcrit (PCT), play an important role in inflammatory and thrombotic processes and the physiopathology of cardiovascular events. AIM: To investigate the association between cardiac syndrome X and PCT and platelet count. MATERIAL AND METHODS: A total of 113 patients with normal coronary angiogram were included in the study. Fifty patients with typical chest pain and evidence of myocardial ischemia in non-invasive tests formed the CSX patient group. The control group consisted of 63 age- and gender-matched patients with normal coronary arteries but without angina. RESULTS: The mean PCT value of the CSX group was significantly higher than that of the control group (0.22 ±0.06 vs. 0.19 ±0.04; respectively, p=0.03). Higher PCT was found to be associated with the presence of CSX in patients with normal coronary arteries by multivariate logistic regression analysis. CONCLUSIONS: We suggest that high PCT may predict the presence of cardiac syndrome X in patients with normal coronary arteries. The value of PCT appears additive to conventional expensive methods commonly used in CSX prediction.

Evaluation of left atrial mechanical function and atrial conduction abnormalities in Maras powder (smokeless tobacco) users and smokers.

OBJECTIVE: In Turkey, a type of smokeless tobacco called Maras powder (MP) is widely used in the south-eastern region. Smokeless tobacco is found in preparations for chewing and for absorption by the nasal and oral mucosae. The purpose of this study was to investigate whether MP damages intra- and inter-atrial conduction delay and left atrial (LA) mechanical function as much as cigarette smoking. METHOD: A total of 150 chronic MP users (50 males, 32.5 ± 5.4 years), smokers (50 males, 32.1 ± 6.0 years) and controls (50 males, 30.1 ± 5.8 years) were included in the study. LA volumes were measured echocardiographically according to the biplane area-length method. Atrial electromechanical coupling was measured with tissue Doppler imaging and LA mechanical function parameters were calculated. RESULTS: The LA passive emptying fraction was significantly decreased and LA active emptying volume (LAAEV) was significantly increased in the MP group (p = 0.012 and p = 0.024, respectively), and the LA active emptying fraction (LAAEF) was significantly increased in the smokers (p = 0.003). There was a positive correlation between the amount of MP used and smoking (pack years) with LAAEV and LAAEF (r = 0.26, p = 0.009 and r = 0.25, p = 0.013, respectively). Lateral atrial electromechanical intervals (PA) were significantly higher in MP users, and the septal mitral PA was statistically higher in the smokers (p = 0.05 and p = 0.04, respectively). CONCLUSION: We suggest that atrial electromechanical coupling intervals were prolonged and LA mechanical function was impaired in MP users and smokers, but there was no significant difference between the MP users and smokers. These findings may be markers of subclinical cardiac involvement and tendency for atrial fibrillation.

Relationship between severity of pulmonary hypertension and coronary sinus diameter.

INTRODUCTION AND OBJECTIVE: We investigated the relationship between coronary sinus (CS) diameter and pulmonary artery systolic pressure (PASP) in patients with pulmonary hypertension (PH) and normal left ventricular systolic function. METHODS: A total of 155 participants referred for transthoracic echocardiography were included in the study. The study population consisted of 100 patients with chronic PH and 55 control subjects. Patients with PH were divided into two groups according to PASP: those with PASP 36-45 mmHg, the mild PH group (n=53); and those with PASP >45 mmHg, the moderate to severe PH group (n=47). CS diameter was measured from the posterior atrioventricular groove in apical 4-chamber view during ventricular systole according to the formula: mean CS=(proximal CS+mid CS+distal CS)/3. RESULTS: Mean CS diameter was significantly higher in the moderate to severe PH group than in the controls and in the mild PH group (1.12±0.2 cm vs. 0.82±0.1 cm and 0.87±0.1 cm, respectively; p<0.001). It was significantly correlated with right atrial (RA) area (r=0.674, p<0.001), RA pressure (r=0.458, p<0.001), PASP (r=0.562, p<0.001), inferior vena cava diameter (r=0.416, p<0.001), right ventricular E/A ratio (r=-0.290, p<0.001), and E/Em ratio (r=0.235, p=0.004). RA area (ß=0.475, p<0.001) and PASP (ß=0.360, p=0.002) were found to be independent predictors of CS diameter. CONCLUSIONS: A dilated CS was associated with moderate to severe pulmonary hypertension, and RA area and PASP were independent predictors of CS diameter.

Coronary sinus dilatation is a sign of impaired right ventricular function in patients with heart failure.

OBJECTIVE: The coronary sinus (CS) has been largely ignored by physicians due to a lack of adequate data about the importance of CS enlargement in patients with heart failure (HF). We aimed to assess whether CS dilatation develops in patients with HF and to demonstrate its relation with global myocardial function of the right ventricle (RV). METHODS: In this cross-sectional study, 45 healthy subjects and 95 HF patients exhibiting left ventricular systolic dysfunction on echocardiographic examination (EF <45%) secondary to ischemic (n=56) or idiopathic dilated cardiomyopathy (DCM) (n=39) were enrolled. Patients with severe renal dysfunction and/or valve disease were excluded. CS was measured by echocardiography from the posterior atrioventricular groove in the apical four-chamber view. The RV myocardial performance index (MPI), which reflects both systolic and diastolic function of the ventricle, was detected using tissue Doppler imaging, and patients with an RV MPI >0.55 were defined as having impaired RV myocardial function. ANOVA, Kruskal-Wallis, Pearson's correlation, and multivariate logistic regression analyses were used for the statistical analysis. RESULTS: The CS and RV MPI values were significantly greater both in patients with ischemic and idiopathic DCM than in controls (8.79±1.7 mm and 8.33±2.1 mm vs. 5.74±0.6 mm, and 0.64±0.07 and 0.62±0.08 vs. 0.43±0.02; p<0.001 for both, respectively). For the prediction of HF patients with impaired RV function, the cut-off value for the diameter of the CS was 7.35 mm, with a sensitivity of 83% and a specificity of 79%. CONCLUSION: The CS diameter can be used as a novel echocardiographic marker that provides information about impaired RV function in patients with HF.