A rare echocardiographic image of aortic prosthetic valve endocarditis complicated with paravalvular abscess, pseudoaneurysm and aorto-right atrial fistula.

Early infectious endocarditis (IE) occurs in 3% of prosthesis in the first 12 months. Early IE is more aggressive than late prosthetic valve endocarditis. Mortality remains high, despite combined medical and surgical treatment. We present a case of early IE in aortic prosthetic valve complicated with paravalvular abscess, pseudoaneurysm and aorto- right atrial fistula.

Diagnosis and Treatment Patterns of Chronic Thromboembolic Pulmonary Hypertension in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia: A Registry Study.

BACKGROUND: Patients with chronic thromboembolic pulmonary hypertension (CTEPH) in countries with limited resources have, to date, been poorly represented in registries. OBJECTIVE: This work assesses the epidemiology, diagnosis, hemodynamic and functional parameters, and treatment of CTEPH in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia. METHODS: A prospective, cohort, phase IV, observational registry with 3-year follow-up (n = 212) in patients aged ≥ 18 years diagnosed with CTEPH was created. Clinical, hemodynamic, and functional parameters were obtained at an initial visit, follow-up visits, and a final visit at the end of 3 years' observation or end of follow-up. Data were recorded on electronic case report forms. Parameters evaluated included 6-minute walking distance (6MWD), use of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), pulmonary hypertension (PH)-targeted therapy, and survival. All statistical analyses were exploratory and descriptive, and were performed in the overall population. RESULTS: The most common symptoms were typical of those expected for CTEPH. Almost 90% of patients underwent right heart catheterization at diagnosis or initial study visit. In total, 66 patients (31%) underwent PEA before the initial visit; 95 patients (45%) were considered operable, 115 (54%) were inoperable, and two (1%) had no operability data. Only 26 patients (12%) had been assessed for BPA at their initial visit. PH-targeted therapy was documented at diagnosis for 77 patients (36%), most commonly a phosphodiesterase type 5 inhibitor (23%). Use of PH-targeted therapy increased to 142 patients (67%) at the initial visit, remaining similar after 3 years. Use of riociguat increased from 6% of patients at diagnosis to 38% at 3 years. Between baseline and end of observation, results for patients with paired data showed an increase in 6MWD. Survival at the end of observation was 88%. CONCLUSIONS: These data highlight the current diagnosis and management of CTEPH in the participating countries. They show that early CTEPH diagnosis remains challenging, and use of off-label PH-targeted therapy is common. CLINICALTRIALS: gov: NCT02637050; registered December 2015.

Blunted heart rate recovery is associated with exaggerated blood pressure response during exercise testing.

Increased sympathetic activity and endothelial dysfunction are the proposed mechanisms underlying exaggerated blood pressure response to exercise (EBPR). However, data regarding heart rate behavior in patients with EBPR are lacking. We hypothesized that heart rate recovery (HRR) could be impaired in patients with EBPR. A total of 75 normotensive subjects who were referred for exercise treadmill test examination and experienced EBPR were included to this cross-sectional case-control study. The control group consisted of 75 age- and gender-matched normotensive subjects without EBPR. EBPR was defined as a peak exercise systolic blood pressure (BP) ≥210 mmHg in men and ≥190 mmHg in women. HRR was defined as the difference in HR from peak exercise to 1 min in recovery; abnormal HRR was defined as ≤12 beats/min. These parameters were compared with respect to occurrence of EBPR. Mean values of systolic and diastolic BP at baseline, peak exercise, and the first minute of the recovery were significantly higher in the subjects with EBPR. Mean HRR values were significantly lower (P < 0.001) in subjects with EBPR when compared with those without. Pearson's correlation analysis revealed a significant positive correlation between the decrease in systolic BP during the recovery and degree of HRR in individuals without EBPR (r = 0.42, P < 0.001). Such a correlation was not observed in subjects with EBPR (r = 0.11, P = 0.34). The percentage of abnormal HRR indicating impaired parasympathetic reactivation was higher in subjects with EBPR (29 % vs 13 %, P = 0.02). In logistic regression analyses, HRR and resting systolic BP were the only determinants associated with the occurrence of EBPR (P = 0.001 and P < 0.001, respectively). Decreased HRR was observed in normotensive individuals with EBPR. In subjects with normal BP response to exercise, a linear correlation existed between the degree of HRR and decrease in systolic BP during the recovery period. However, such a correlation was not found in subjects with EBPR. Our data suggest that mechanisms underlying the blunting of the HRR might be associated with the genesis of EBPR. The association between the extent of HRR and adverse cardiovascular outcomes in patients with EBPR needs to be investigated in detail in future research.

Effects of Smoking on Very-Long Term Mortality after First ST Elevation Myocardial Infarction. / Efeitos do Ato de Fumar na Mortalidade de Longo Prazo após Infarto do Miocárdio por Elevação de ST.

BACKGROUND: The smoking paradox has been a matter of debate for acute myocardial infarction patients for more than two decades. Although there is huge evidence claiming that is no real paradox, publications supporting better outcomes in post-MI smokers are still being released. OBJECTIVE: To explore the effect of smoking on very long-term mortality after ST Elevation myocardial infarction (STEMI). METHODS: This study included STEMI patients who were diagnosed between the years of 2004-2006 at three tertiary centers. Patients were categorized according to tobacco exposure (Group 1: non-smokers; Group 2: <20 package*years users, Group 3: 20-40 package*years users, Group 4: >40 package*years users). A Cox regression model was used to estimate the relative risks for very long-term mortality. P value <0.05 was considered as statistically significant. RESULTS: There were 313 patients (201 smokers, 112 non-smokers) who were followed-up for a median period of 174 months. Smokers were younger (54±9 vs. 62±11, p: <0.001), and the presence of cardiometabolic risk factors were more prevalent in non-smokers. A univariate analysis of the impact of the smoking habit on mortality revealed a better survival curve in Group 2 than in Group 1. However, after adjustment for confounders, it was observed that smokers had a significantly increased risk of death. The relative risk became higher with increased exposure (Group 2 vs. Group 1; HR: 1.141; 95% CI: 0.599 to 2.171, Group 3 vs Group 1; HR: 2.130; 95% CI: 1.236 to 3.670, Group 4 vs Group 1; HR: 2.602; 95% CI: 1.461 to 4.634). CONCLUSION: Smoking gradually increases the risk of all-cause mortality after STEMI.

FUNDAMENTO: O paradoxo do fumante tem sido motivo de debate para pacientes com infarto agudo do miocárdio (IM) há mais de duas décadas. Embora haja muitas evidências demonstrando que não existe tal paradoxo, publicações defendendo desfechos melhores em fumantes pós-IM ainda são lançadas. OBJETIVO: Explorar o efeito do fumo na mortalidade de longo prazo após infarto do miocárdio por elevação de ST (STEMI). MÉTODOS: Este estudo incluiu pacientes com STEMI que foram diagnosticados entre 2004 e 2006 em três centros terciários. Os pacientes foram categorizados de acordo com a exposição ao tabaco (Grupo 1: não-fumantes; Grupo 2: <20 pacotes*anos; Grupo 3: 2-040 pacotes*anos; Grupo 4: >40 pacotes*anos). Um modelo de regressão de Cox foi utilizado para estimar os riscos relativos para mortalidade de longo prazo. O valor de p <0,05 foi considerado como estatisticamente significativo. RESULTADOS: Trezentos e treze pacientes (201 fumantes e 112 não-fumantes) foram acompanhados por um período médio de 174 meses. Os fumantes eram mais novos (54±9 vs. 62±11, p: <0,001), e a presença de fatores de risco cardiometabólicos foi mais prevalente entre os não-fumantes. Uma análise univariada do impacto do hábito de fumar na mortalidade revelou uma curva de sobrevivência melhor no Grupo 2 do que no Grupo 1. Porém, após ajustes para fatores de confusão, observou-se que os fumantes tinham um risco de morte significativamente maior. O risco relativo tornou-se maior de acordo com a maior exposição (Grupo 2 vs. Grupo 1: RR: 1,141; IC95%: 0,599 a 2.171; Grupo 3 vs. Grupo 1: RR: 2,130; IC95%: 1,236 a 3,670; Grupo 4 vs. Grupo 1: RR: 2,602; IC95%: 1,461 a 4,634). CONCLUSÃO: O hábito de fumar gradualmente aumenta o risco de mortalidade por todas as causas após STEMI.

Index of cardiac-electrophysiological balance and the effects of thrombolytic therapy on the electrocardiogram of patients with pulmonary embolism.

OBJECTIVE: Different parameters on electrocardiograms (ECG) have been investigated to predict arrhythmia and mortality in patients with acute pulmonary embolism (APE). The acute effect of thrombolytic therapy (TT) on these parameters has not been investigated yet. METHODS: We examined the data of 83 patients who were evaluated as high-risk APE and discharged from the hospital after TT. First, the high-risk APE patients' ECGs were compared with healthy control subjects (n = 55). After their admission and 24 hours later, the ECGs of patients with APE were compared. Heart rate, P-wave morphology, QRS duration, QT distance, Tp-e, and the index of cardiac electrophysiological balance (iCEB) were analyzed. RESULTS: Although P maximum was not different between the groups' ECGs, heart rate, QT, QTc (corrected QT) interval, Tp-e intervals, Tp-e/QT ratio, and P wave dispersion were significantly higher in the APE group ( P values < 0.031). iCEB or iCEBc (corrected iCEB) values were lower in APE group ( P < 0.001). After TT, we determined a decrease in heart rate, Tp-e interval, and Tp-e/QT ratio ( P < 0.001). Although we detected a decrease in the QT and QTc interval and QT dispersion (QTd), QTd had no statistical significance (respectively P -value 0.013, 0.029, and 0.096). The iCEB and iCEBc levels were lower after TT ( P -value was 0.035 and 0.044 respectively). CONCLUSION: The QT, QTc, Tp-e interval, Tp-e/QTc ratio, iCEB, and iCEBc values significantly decreased after TT. It may be thought that effective TT causes partial improvement in ventricular repolarization in an early period.

The comparative effects of long-term carvedilol versus bisoprolol therapy on QT dispersion in patients with chronic heart failure.

OBJECTIVES: Carvedilol and bisoprolol reduce QT dispersion (QTD) in chronic heart failure (CHF). However, it is unclear whether there is a difference between the effects of the two drugs. The aim of the present study was to compare the long-term effects of carvedilol and bisoprolol on QTD in patients with CHF. METHODS: Eighty-one patients with CHF with no previous beta-blocker therapy were included in this prospective study. The patients were randomly allocated to carvedilol or bisoprolol therapy. Left ventricular ejection fraction (LVEF), heart rate (HR), QTD, and corrected QTD (QTcD) were calculated at baseline and at the 6th month of therapy. RESULTS: In comparison to baseline values in both therapy groups, LVEF was significantly improved, and a statistically significant decrease was found in HR (carvedilol from 76 +/- 12 to 65 +/- 10 beats/min, p < 0.001; bisoprolol from 78 +/- 13 to 65 +/- 8 beats/min, p < 0.001) and QTcD (carvedilol from 85 +/- 28 to 65 +/- 22 ms, p < 0.001; bisoprolol from 83 +/- 22 to 61 +/- 20 ms, p < 0.001). In our study, carvedilol and bisoprolol were found to have similar effects on LVEF, HR, and QTcD. CONCLUSIONS: Carvedilol and bisoprolol decrease HR and QTcD in patients with CHF, and there is no meaningful difference between the two beta-blockers as regards their effects on these parameters.

Platelet glycoprotein Ibalpha gene polymorphism and massive or submassive pulmonary embolism.

OBJECTIVE: The -5T/C polymorphism in the Kozak sequence of glycoprotein Ibalpha, a component of the platelet glycoprotein Ib-IX-V receptor complex, is associated with an increase in this receptor density on the surface of the platelet. This study was designed to investigate the effect of platelet glycoprotein Ibalpha Kozak polymorphism on the clinical presentation of the patients with acute pulmonary embolism. METHODS: Forty-two patients with pulmonary embolism were genotyped for Kozak polymorphism of the glycoprotein Ibalpha by polymerase chain reaction/restriction fragment length polymorphism. RESULTS: Carriers of the -5T/C polymorphism of glycoprotein Ibalpha were significantly over-represented in the patient group with clinically massive or submassive pulmonary embolism (odds ratio 5.5, 95% confidence interval 1.4 to 22.2, P = 0.023). Also the association between this polymorphism and massive or submassive pulmonary embolism still existed even after being adjusted for conventional risk factors. CONCLUSION: The -5T/C polymorphism in the Kozak sequence of glycoprotein Ibalpha may present as a risk factor for clinical manifestation of pulmonary embolism in which clot burden plays an important role.

Comparison of myocardial performance index obtained either by conventional echocardiography or tissue Doppler echocardiography in healthy subjects and patients with heart failure.

This study was planned to investigate the normal reference values of myocardial performance index (MPI) obtained by tissue Doppler echocardiography (TDE) and the agreement between MPI measured by TDE and conventional MPI measured by pulsed-wave Doppler (PWD) in healthy subjects and patients with heart failure (HF). Two hundred and three patients with HF and 190 healthy subjects were enrolled in this study. Isovolumic contraction and relaxation time (ICT and IRT) and ejection time (ET) were measured from mitral inflow and left ventricular (LV) outflow. Tissue Doppler echocardiography recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus and same time intervals were measured. Myocardial performance index was calculated. The functional capacity of the patients with HF was determined according to New York Heart Association classification. TDE-MPI values were higher than conventional PWD-MPI values in both groups (53%+/-8% vs 48%+/-11%, P<0.0001 in the healthy subjects; 84%+/-21% vs 72%+/-19%, P<0.0001 in the patients with HF). Moderate agreement was found between PWD-MPI and LV mean TDE-MPI in both groups. In identifying patients with moderately or severely decreased LV ejection fraction, TDE-MPI had higher cutoff values than conventional PWD-MPI, and TDE-MPI had higher specificity, sensitivity, negative predictive value, and diagnostic accuracy. In patients with HF, TDE-MPI had a stronger correlation with LV ejection fraction and functional capacity than did PWD-MPI. TDE-MPI is an alternative to conventional PWD-MPI in assessment of cardiac function. However, the higher MPI cutoff points should be considered when this method is used for the evaluation of cardiac function.

The effect of nondipping blood pressure patterns on cardiac structural changes and left ventricular diastolic functions in normotensives.

BACKGROUND: Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives. METHODS: We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24-hour ambulatory BP < 130/80 mmHg. RESULTS: In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =-0.27, P = 0.027; coefficient =-0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively). CONCLUSIONS: Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

Type II bidirectional ventricular tachycardia in a patient with myocardial infarction.

A 84-year-old man presented to the emergency department complaining of chest pain and palpitations. He had no history of coronary artery disease. The 12-lead electrocardiography showed bidirectional ventricular tachycardia (BVT). Coronary angiography revealed severe mid left anterior descending and mid left circumflex lesions. The BVT, in this case, was most likely due to myocardial ischema. The ethiology of published BVT cases are most commonly digitalis toxicity and rarely herbal aconitine poisoning, hypokalemic periodic paralysis, cathecolaminergic VT, myocarditis, and Anderson-Tawil syndrome. The patient had neither of these underlying conditions. To the best of our knowledge and research in the literature, there was no report of bidirectional VT in the patients with myocardial infarction.

Association between depression and anxiety scores and inflammation in patients with isolated coronary artery ectasia.

OBJECTIVE: Depression and anxiety disorders are frequently found in combination with obstructive coronary artery disease. Coronary artery ectasia (CAE) is an atypical form of coronary artery disease, the etiology of which has not yet been clearly defined. The aim of this study was to assess the existence of a relationship between anxiety/depression and CAE. METHODS: A CAE group (n=41; mean age: 58.9±9.0 years) and a control group (n=42; mean age: 58.0±9.6 years) were compared. The anxiety and depression status of patients was evaluated using the Hospital Anxiety and Depression Scale (HADS) questionnaire. RESULTS: Age, sex, ejection fraction, and cardiovascular risk factor data were similar in both groups. The serum Creactive protein (CRP) and uric acid levels as well as the leukocyte count were significantly higher in the CAE group (p<0.05). The HADS anxiety score was higher in the CAE group, but without statistical significance (p=0.23). The HADS depression score and total HADS score was significantly higher in the CAE group (p<0.001 and p<0.001). The total HADS score and the HADS depression score were correlated with the serum CRP level (r=0.489; p<0.001 and r=0.543; p<0.001, respectively), whereas the anxiety score was not correlated with CRP (r=0.85; p=0.23). CONCLUSION: The depression score, CRP, and uric acid levels were greater in patients with isolated CAE compared with those of patients with normal coronaries. The anxiety score did not demonstrate a relationship to CAE; however, there was an association between the depression score and CRP, which is an inflammatory marker.

Comparison of increased aspirin dose versus combined aspirin plus clopidogrel therapy in patients with diabetes mellitus and coronary heart disease and impaired antiplatelet response to low-dose aspirin.

The effects of therapy with aspirin 300 mg/day and with combined aspirin 100 mg/day plus clopidogrel 75 mg/day on platelet function were compared in patients with diabetes mellitus and coronary artery disease and impaired antiplatelet responses to aspirin 100 mg/day. The study population consisted of 151 outpatients with type II diabetes mellitus and coronary artery disease who were taking aspirin 100 mg/day. Of the 151 patients, a subgroup of subjects with impaired aspirin response were selected on the basis of the results of platelet aggregometry. Nonresponsiveness to aspirin was defined as mean aggregation > or =69% with 3 micromol/L adenosine diphosphate and mean aggregation > or =70% with 2 micromol/L collagen. Aspirin semiresponders were defined as meeting 1 but not both of these criteria. Nonresponders and semiresponders were randomized equally to aspirin 300 mg/day and aspirin 100 mg/day plus clopidogrel 75 mg/day, and aggregation tests were repeated after 2 weeks. Sixty of the 151 patients with diabetes (40%) were found to respond to aspirin inadequately. Platelet aggregation induced by adenosine diphosphate and collagen decreased significantly after aspirin 300 mg/day or combined therapy. Combined treatment was found to have a stronger inhibitory effect on platelet aggregation induced by adenosine diphosphate than aspirin 300 mg/day (p = 0.002). Impaired aspirin response was resolved by increasing the aspirin dose or adding clopidogrel to aspirin (p <0.0001 for each). However, desired platelet inhibition was achieved in significantly more patients by combined treatment than by aspirin 300 mg/day (p <0.05). In conclusion, aspirin 100 mg/day does not inhibit platelet function adequately in a significant number of patients with diabetes mellitus and coronary artery disease. Increasing the aspirin dose to 300 mg/day or adding clopidogrel to aspirin can provide adequate platelet inhibition in a significant number of those patients with impaired responses to low-dose aspirin.

Relationship between systolic myocardial velocity obtained by tissue Doppler imaging and left ventricular ejection fraction: systolic myocardial velocity predicts the degree of left ventricular dysfunction in heart failure.

This study was planned to research the relationship between systolic myocardial velocity (Sm) obtained by tissue Doppler imaging (TDI) and left ventricular ejection fraction (LVEF) measured according to conventional Simpson's method in healthy subjects and patients with heart failure (HF). Two hundred eight patients with HF whose LVEF < 50% (mean age 59 +/- 11 years) and 187 healthy subjects (mean age 57 +/- 11 years) were enrolled in this study. LVEF was measured and TDI recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus, and Sm was measured. LV mean Sm was calculated. In patients with HF, a significant correlation was detected between LVEF and Sm (r = 0.71, P < 0.0001), while no relationship was found between these parameters in healthy subjects (r = 0.16, not significant). The cutoff value of Sm < 8 cm/s for identifying patients with LVEF between 30% and 49% had a sensitivity of 86%, a specificity of 93%, and a negative predictive value of 92%, and the cutoff value of Sm < 6.0 cm/s for identifying patients with LVEF < 30% had a sensitivity of 92%, a specificity of 84%, and a negative predictive value of 97%. The time required to calculate the LVEF was significantly longer than that of LV mean Sm (327 +/- 98 sec vs. 110 +/- 29 sec, P < 0.0001), and LVEF had higher inter- and intraobserver variability. LV mean Sm obtained by TDI, a parameter that is reproducible, easily obtained, reliable, and practical, can be used to evaluate LV systolic function in patients with HF.

Is there any relationship between metabolic parameters and left ventricular functions in type 2 diabetic patients without evident heart disease?

BACKGROUND: The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M-mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. METHODS: Seventy-two patients with T2DM (mean age 49.1 +/- 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 +/- 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M-mode flow propagation velocity (V(E)). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA(1C) level were determined. The association of FBG, PPG and HbA(1C) with the echocardiographic parameters was investigated. RESULTS: It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA(1C) was found to be related to diastolic parameters such as E/A, Em/Am, V(E) and E/V(E) (beta=-0.314, P = < 0.05; beta=-0.230, P < 0.05; beta=-0.602, P < 0.001, beta= 0.387, P < 0.005, respectively). In addition to HbA(1C), LV, diastolic functions were also correlated with age and diabetes duration. CONCLUSION: Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA(1C) levels may affect diastolic parameters.

An unusual electrocardiographic presentation of acute obstruction of the left anterior descending coronary artery.

Acute obstruction of the left anterior descending coronary artery is generally presented electrocardiographically as isolated anterior or combined anterior and inferior ST-elevation myocardial infarction. We described an isolated inferolateral ST-elevation myocardial infarction due to acute occlusion of the distal left anterior descending coronary artery.

Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardiographic predictor of poor prognosis.

BACKGROUND: We aimed to investigate the value of ST elevation in lead aVR (ST upward arrow aVR) in predicting the left anterior descending coronary artery (LAD) occlusion site proximal to first septal perforator (S(1)) and its effect on in-hospital outcome in ST-elevation myocardial infarction (STEMI). METHODS: The study included 950 patients with STEMI. Patients were divided into 2 groups as aVR(+) and aVR(-) according to the presence of an ST upward arrow aVR of 0.5 mm or greater. RESULTS: ST elevation in lead aVR was seen in 155 (16%) patients, and LAD occlusion proximal to S(1) was detected in 52% of patients in the aVR(+) group and in 9% of patients in the aVR(-) group. aVR positivity was associated with higher heart rate, lower systolic blood pressure and ejection fraction, and worse Killip class at the hospital admission. In-hospital mortality was 19% in the aVR(+) group and 5% in the aVR(-) group. aVR positivity was an independent predictor of in-hospital death. CONCLUSION: This study revealed that ST upward arrow aVR was not only a good indicator of LAD occlusion proximal to S(1) but also a source of valuable information about in-hospital outcome in patients with STEMI.

[The role of tissue Doppler echocardiography in the evaluation of functional capacity of patients with heart failure]. / Kalp yetersizligi olan hastalarda fonksiyonel kapasitenin degerlendirilmesinde doku Doppler ekokardiyografinin rolü

OBJECTIVES: We investigated correlations between the New York Heart Association (NYHA) functional classification system, which is commonly used to assess functional capacity, and conventional echocardiographic and tissue Doppler echocardiographic (TDE) parameters in patients with heart failure (HF). STUDY DESIGN: The study included 122 patients (31 females, 91 males; mean age 59+/-11 years) with HF, whose left ventricular (LV) ejection fraction (EF) was less than 50%. The patients were evaluated in two groups based on the NYHA class I-II (n=79; mean age 58 years) and class III-IV (n=43; mean age 61 years). Correlations were sought between the functional status and standard two-dimensional echocardiographic and TDE parameters. RESULTS: The NYHA class showed significant inverse correlations with LV EF, LV stroke volume, mitral deceleration time of early filling, and flow propagation velocity (Vp), and significant positive correlations with end-systolic and end-diastolic diameters and volumes, pulmonary artery pressure (PAP), and the E/Vp ratio. Mitral early (E) and late (A) diastolic peak velocities and the E/A ratio were not correlated. Concerning TDE parameters, the NYHA class was in significant inverse correlation with systolic (Sm), early (Em) and late (Am) diastolic myocardial velocities, and in positive correlation with the E/Em ratio, whereas no correlation was found with the Em/Am ratio. Linear regression analysis showed that Sm, EF, and PAP were independent variables of functional capacity (beta =-0.33, p<0.005; beta =-0.26, p<0.05; beta =0.23, p<0.05, respectively). CONCLUSION: There is significant relationship between myocardial velocities and functional capacity, and Sm, in particular, has the strongest association compared to conventional echocardiographic and other TDE parameters.

Influence of menstrual cycle on cardiac performance.

OBJECTIVES: The purpose of this study was to investigate the relationship between endogen sex hormone levels and myocardial performance in two different phases of menstrual cycle. BACKGROUND: The relationships between cardiac performance and sex hormone levels in menstrual cycle have not yet been clearly identified. METHODS: Twenty-seven women at the age of 19-42 years (mean 24.11+/-6.02) with regular menstrual cycles (28-31 days) were enrolled in this study. Cardiac performance was evaluated by tissue Doppler imaging (TDI) derived myocardial performance index (MPI) in the menstrual and the luteal phases of the menstrual cycle. RESULTS: Left ventricular MPI were statistically significant between the menstrual phase and luteal phase of the menstrual cycle (Inferior 0.53+/-0.10 versus 0.44+/-0.09, P<0.001; Anterior 0.54+/-0.13 versus 0.45+/-0.10, P<0.008; Lateral 0.50+/-0.09 versus 0.44+/-0.12, P<0.03; Septum 0.54+/-0.07 versus 0.46+/-0.10, P<0.005; Global 0.52+/-0.06 versus 0.44+/-0.09, P<0.001). Right ventricle MPI between the two periods was also significantly different (0.49+/-0.10 versus 0.42+/-0.10, P<0.01). There was a moderate correlation between estrogen levels and global MPI (r=0.46, P=0.001), but no correlation was found between progesterone levels and global MPI (r=0.22, P=NS). CONCLUSION: We firstly demonstrated that endogen estrogen or progesterone improved the combined systolic and diastolic function in both left and right ventricle during luteal phases of menstrual cycle. Considering the previous studies and our results, estrogen may be responsible for this improvement.

Effect of preload and heart rate on the doppler and tissue doppler-derived myocardial performance index.

UNLABELLED: Doppler-derived myocardial performance index (MPI) has been described as a noninvasive measurement of LV function. Our aim was to investigate the effect of hemodialysis related volume reduction and heart rate changes on the Doppler-derived LV MPI, and Doppler tissue imaging (DTI) derived left and right ventricular MPI. METHOD: The study group comprised 32 consecutive patients (mean age: 43 +/- 18 yrs) undergoing hemodialysis. Patients underwent echocardiography before and immediately after hemodialysis session. Left and right ventricular MPI derived from conventional pulsed-wave Doppler and DTI was calculated. The difference in MPI, heart rate and body weight was calculated before and after hemodialysis. RESULTS: Doppler-derived LV MPI, and right ventricular MPI obtained by DTI were increased (p = 0.05) but the LV MPI obtained by DTI was unchanged after hemodialysis. There is a significant positive correlation between the Doppler-derived LV MPI difference and volume reduction (r = 0.38, p = 0.032). The heart rate difference was correlated with Doppler-derived LV MPI difference, and DTI derived right ventricular MPI difference (r = 0.38, p = 0.034; r = 0.48, p = 0.006, respectively). Whereas, DTI derived LV MPI difference was not correlated with heart rate difference. By the multivariate analysis, there was no correlation between Doppler-derived LV MPI difference with heart rate difference, and volume reduction. Right ventricular MPI difference correlated with heart rate difference (r = 0.41, p = 0.021) but not with volume reduction. Doppler-derived MPI is partially influenced by preload and heart rate changes. However, DTI derived LV MPI is not influenced by preload and heart rate changes.

Full metal jacket: transfemoral aortic valve implantation for regurgitant valve after endovascular aortic repair.

Transfemoral aortic valve implantation has become an almost routine interventional procedure for severe aortic stenosis in high-risk patients. Over time an increased number of experiences has led to unusual procedures. In this report, we present a successful valve-in-valve transfemoral aortic valve implantation in a patient with aortic regurgitation, who previously had debranching and thoracic endovascular aortic repair operations.